The MH 5253 form serves as a critical document in the nexus between the healthcare and legal systems, specifically tailored for referrals to inpatient forensic evaluations. Designed meticulously to account for all necessary information, this form encapsulates the essence of transferring a service recipient, who may be involved in legal proceedings, from one facility to another with a focus on their mental health needs. The structured sections demand comprehensive details such as the identification of both the receiving and referring facilities, the date of referral alongside the timing of any outpatient evaluations conducted, the service recipient's personal information including their social security number and date of birth, and the legal context marked by charges and custody status if applicable. Further, it delves into the clinical domain, seeking insights into the recipient's current mental health status, previous interventions undertaken to avert the need for an inpatient referral, the clinical rationale behind the referral, ongoing medications, medical concerns, and any historical mental health treatments. Moreover, it emphasizes the importance of including relevant documents alongside the referral, such as evaluations, military records, or risk assessments, to ensure a holistic understanding of the individual's situation. This form plays a pivotal role in bridging the informational gap between healthcare providers and the legal system, aiming to align on the best course of action for individuals at the intersection of mental health challenges and legal scrutiny.
| Question | Answer |
|---|---|
| Form Name | Form Mh 5253 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | form, 4N6, Competency, Inpatient |
Referral Form for Inpatient Forensic Evaluation
Receiving Facility: |
__________________________________________ |
|||
Referring Facility: |
__________________________________________ |
|||
Date of Referral: _____________________ |
Date of Outpatient Evaluation: ___________________ |
|||
Name of Service Recipient: |
________________________________________________________________________ |
|||
Social Security Number: ___________________________ |
Date of Birth: ________________________________ |
|||
Charge(s): ______________________________________ |
Docket #: ___________________________ |
|||
_______________________________________________ |
DCS Custody (if juvenile): |
Yes ______ No ______ |
||
Date(s) of Alleged Crime: ____________________________ |
Current Location/Placement: ______________________ |
|||
County: _________________________________________ |
Prosecutor: __________________________________ |
|||
Judge: ______________________________________ |
Defense Atty: ________________________________ |
|||
Clinical Information: ____________________________________________________________________________
_____________________________________________________________________________________________
List All Interventions Used to Prevent Referral: |
____ Malingering Exam |
____ Medication Intro/Adjust |
____ Contacted Judge or Attorney(s) ____ Competency Training |
____ Psychological Testing (specify):_____________________________ |
|
____ Other (specify): ______________________________________________________________________________
Reason for Referral to Inpatient Facility: (Specify Clinical Rationale - Do Not State "For Forensic Evaluation") __________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Reason for Referral to FSP [ADULT ONLY] (Specify Clinical Rationale): ____________________________________
_____________________________________________________________________________________________
Current Medications: ____________________________________________________________________________
_____________________________________________________________________________________________
Current Medical Concerns: ________________________________________________________________________
_____________________________________________________________________________________________
Current and/or Previous Mental Health Treatment: Yes ______No ______
Facility: ________________________________________________________________________________
Past Forensic Evaluation (Where and When): _______________________________________________________
_____________________________________________________________________________________________
Date of Phone Contact with the Receiving Forensic Coordinator: ____________________________________________________
Name of CMHC Person Making Referral: ___________________________________________________
Phone Number of CMHC Person Making Referral: ____________________________________
Information Included: _____ C/4N6 Evaluation |
______ Military Records |
______ Witness Reports |
_____ Jail/Court Records |
_____ School/Employment Records |
_____ Risk Assessment |
_____ Attorney Records |
_____ Past Treatment Records |
_____ Other: _________ |
_____ Medical Records |
_____ A & D Records |
_____________________ |
|
|
_____________________ |
MH 5253 (Rev. 9/11)