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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