BQuIP Screening Report 2-26-20



|Screening Results |

|Patient is seeking help for: ( Mental Health ( Physical Health ( Substance use disorder |

| |

|Area |Rating |Critical issues and other referral considerations | |

| |(none, low, |CRITICAL ISSUES | |

| |moderate, high, |Daily activities impaired by MH symptoms | |

|Mental Health Needs |N/A) |Thoughts of harm to self: current & last 30 days | |

| | |Thoughts of harm to others: current & last 30 days | |

| | |Co-occurring disorders/mental health evaluation is recommended. (Severe) | |

| | |Referral Considerations: | |

| | |Co-occurring disorders/mental health evaluation is recommended | |

| | |Psychiatric meds: last 12 months/lifetime use of psychiatric medications | |

| | |Thoughts of harm to others: in last 30 days | |

| | |Thoughts of harm to self: in last 30 days | |

| | |CRITICAL ISSUES |

|Substance Use | |WM: URGENT priority for a withdrawal management medical assessment |

| | |CNS Depressants: Use of at least two (2) Central Nervous System (CNS) |

|Withdrawal Risk: | |Overdose risk: Recommend naloxone to reverse opiate overdose |

| | | |

| | |Referral Considerations: |

|Relapse Risk: | |WM: Recommend medication assisted treatment (MAT) for alcohol use |

| | |WM: Recommend medication assisted treatment (MAT) for opioid use |

|Recovery Environment | |Recovery environment support service needs should be evaluated |

|Risk: | |Readiness to change: low, moderate, high, N/A |

| | |Consider Initial Placement for SUD: |

| | |SUD services NOT indicated at time of screening |

| | |Narcotic/Opioid Treatment Program, Office-based opioid treatment (OBOT), or Outpatient Suboxone Clinic, |

| | |Outpatient SUD setting, |

| | |Intensive Outpatient SUD setting, |

| | |Residential SUD setting |

| |(none, mild, | |

| |moderate, severe,| |

| |N/A) | |

| | (none, mild, | |

| |moderate, severe,| |

| |N/A) | |

| | (none, mild, | |

| |moderate, severe,| |

| |N/A) | |

| |(none, low, |CRITICAL ISSUES | |

| |moderate, high, |Daily activities impaired by physical condition | |

|Physical Health Needs |N/A) |Injection drug use: in last 12 months. High priority for medical follow up regarding injury/illness associated with | |

| | |injection drug use | |

| | |Pregnancy: Possible pregnancy _________________________________________________________ | |

| | |Referral Considerations: | |

| | |Medical evaluation is recommended | |

|Additional Services |Social supports reported: Yes, No | |

| |Homeless: High priority for follow-up | |

| |Criminal Justice involvement: in last 12 months, released in last 2 weeks, Date of release:_________ | |

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