New Mexico Behavioral Health Providers Association



RMCHCS Substance Abuse Treatment Center650 Vanden Bosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778Admission Requirements/ChecklistOur goal is to make an appropriate decision for admission to our 90-day residential treatment and ensure that RMCHCS Substance Abuse Treatment Center can provide quality services and care to all clients. Please check off the following admission criteria and attach to the completed packet. ALL FORMS MUST BE FILLED OUT AND CHECKED OFF – FAILURE TO INCLUDE ALL DOCUMENTATION WILL RESULT IN DELAY OF PROCESSING APPLICATION. PLEASE ALLOW APPROXIMATELY 2-3 WEEKS FOR A DECISION TO BE MADE REGARDING ADMISSION. Alcohol and drug testing may be performed at any time during your stay at our facility. _____1. Completed application form (provided). Be honest when answering, as any falsified information may result in either a delay in admission or an immediate discharge from treatment. _____2. Reciprocal release of information, as applicable (provided). Release must be completely filled out to be valid.______ 3. Written Letter of Commitment for admission and treatment (provided).______ 4. Full psychological or psychiatric evaluation. Must be completed by a licensed clinician prior to admission. _____5. ASAM Severity Profile (provided). Must be completed by LADAC, LPCC, LMHC, LISW, or LMSE. _____6. Mental Health Screening and PHQ-9 must be completed by a licensed clinician prior to admission. _____7. Medical Clearance (provided) including Medication Orders. Must be completed by a physician. _____8. Other Important documents: ID or Driver’s License, SS card, Birth Certificate, CIB, medical insurance card and immunization records. (Bring them with you at time of admission. No Copies)______9. Labs: Hepatitis B and C, HIV, T. pallidum Ab/RPR (Syphilis), Gonorrhea, Chlamydia. Must be done within one month prior to admission._____10.Tuberculosis (TB) skin test. Must be done within one month prior to admission. _____11. Court Order, if applicable.You will be automatically denied admission to the facility if any of the following situations are not met:You must be completely sober (no drinking, drugs, etc.) at the time of admission. This includes the withdrawal process. For detox or withdrawal symptoms, our facility will refer you to a medical institution, such as RMCHCS, IHS, or another medical facility. You cannot have been arrested, charged, or convicted of a sexually-based offense. You must arrange your own transportation to the facility. The day that you are scheduled will be the day that you are admitted. If you bring cash, do not bring more than $50 with you to the facility.You will be tested for alcohol and/or drugs at the time of admission. We have a no tolerance policy.You will need to bring 5 sets of clothing (pants, shirts, underwear, socks, 2-pair of shoes) and hygiene items to last at least 30 days. (alcohol free) Friends and/or family will be permitted to bring other items as needed.You cannot be admitted to the facility at the same time as a family member, friend, or other acquaintance.You cannot be on a prescription narcotic medication, to include methadone and other similar medications.You must be medically stable, as defined as:Having a favorable medical prognosis and stable vital signsHaving no severe emotional instability or severe personality disordersBeing able to function on your own (ambulates, communicates, eats, bathe, etc.)Being able to attend group sessions, participate in recreation, etc.RMCHCS Substance Abuse Treatment Center650 Vanden Bosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778Program Information(Keep for Your Information)RMCHCS Substance Abuse Treatment Center is a low-intensity, clinically managed, 50-bed, 90-day treatment facility for men and women. Our facility is located on the East Campus of Rehoboth McKinley Christian Health Care Services at 650 Vanden Bosch Parkway in Gallup, New Mexico. RMCHCS Substance Abuse Treatment Center is a 90-day treatment facility that offers healing and transition for people with chemical dependence problems on the road to recovery. It is our goal to provide an environment which will support motivation to obtain and maintain an individual’s decision to remain clean and sober. While at RMCHCS Substance Abuse Treatment Center, clients will participate in a treatment program that will include the following:Individual CounselingFamily CounselingGroup CounselingPsych educational groups will entail Alcohol/Drug Prevention and Education with an emphasis on Relapse Prevention Skills. The Healthy Relationships group will explore Anger Management Skills with an emphasis on Assertiveness Communication. Alcoholics Anonymous, Narcotics Anonymous, as well as Al-ANON groups are held on site. Our staff will integrate case management goals throughout the program. This will include assisting clients with basic life skills such as finance/time management skills, health/nutrition skills, and career counseling. Client will also be referred to appropriate local/regional resources as needed. Family visitation will be scheduled as time allows. Your support is welcomed and encouraged on behalf of your loved ones. The client will participate in family counseling services through their primary counselor.VISITS: After a client has completed 30 days in the program, the client is permitted family visits coordinated with primary counselor. Visitors must sign the Visitor Log upon arrival and departure. Children are welcome; however, they must be watched and supervised at all times.Visitation is only allowed in the designated area. You are not allowed to visit in vehicles or any non-designated visiting area. Staff on duty is required to and is responsible for checking specified areas periodically throughout the duration of the visitations. Any violation will result in having the family asked to leave the premises. Any visitor who appears to be under the influence of alcohol and/or drugs will be asked to leave immediately. Clients may refuse to see visitors. Visits and visitors may be limited due to therapeutic issues, at the discretion of the primary counselor. No outside food or drinks are permitted. RMCHCS Substance Abuse Treatment Center650 VandenBosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778(Keep for Your Information)CONFIDENTIALITY: For confidentiality and privacy of clients, visitors are not allowed inside RMCHCS Treatment Areas.TELEPHONE CALLS: RMCHCS Substance Abuse Treatment Center, as time permits, will allow clients to make phone calls after the initial 30-day blackout. Use of the telephone may also be limited at the discretion of the primary counselor.EMERGENCIES: Emergency calls to 505-726-6919 will be accepted.Please remember that clients may not be available at the time you call. Please leave a message regarding the emergency situation and staff will assist your family in responding as soon as possible. MAIL: While in treatment, clients may receive mail at the address noted below. Please address as follows:RMCHCS Substance Abuse Treatment CenterAttn: [Client’s Name]650 Vanden Bosch ParkwayGallup, NM 87301MAIL IS SUBJECT TO INSPECTIONWe are looking forward to meeting and working with you and your family.Thank you for your interest and support.-Staff at RMCHCS Substance Abuse Treatment CenterRMCHCS Substance Abuse Treatment Center650 Vanden Bosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778(Keep for Your Information)At admission and otherwise, all personal items will be screened and inventoried. Clients are required to inform staff of all items brought into the RMCHCS Substance Abuse Treatment Center. Items will be added to the client’s inventory. APPROVED ITEMS:Plastic shower shoes or flip-flops are mandatory – you are required to wear shower shoes in the shower at all fortable/appropriately fitting clothing to last at least one (1) week. No sagging or hot pants are acceptable. A belt must be worn at your waist and may not hang below your waist. Bring a jacket and/or sweatshirts appropriate for the season. NO LARGE BELT BUCKLES ARE PERMITTED.Warm-ups/sweats and tennis shoes are acceptable. T-shirts are acceptable but cannot contain gang, violence, or alcohol/drug content. Knee length shorts ONLY are to be worn in the Sweat Lodge. (You will be exercising daily.)Please bring your own blanket, pillow, towels, and washcloths.Please bring your own toiletries:ToothpasteShampoo and conditionerShaving creamPersonal grooming items (comb, brush, etc.)Female Clients: Please bring your own female sanitary napkins and products for your 90-day treatment stay.Laundry detergent and liquid fabric softener are the responsibility of the client (high efficiency recommended). Personal items may be dropped off during scheduled visitations. Personal items will be screened and added to the client’s inventory. If any request for drop-off is determined to be non-therapeutic by the primary counselor, drop off with not be permitted.If personal belongings are left behind at discharge, RMCHCS Substance Abuse Treatment Center is not liable for such items. Reasonable efforts will be made by staff to safeguard any items left behind for up to 1 month. RMCHCS Substance Abuse Treatment Center650 Vanden Bosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778ITEMS NOT ALLOWED(Keep for Your Information)NO cellular phones, pagers, portable movie players, laptops, stereos, TVs, recorders, radios, mp3 players, earphones, cameras, or video gaming machines allowed. Knives, weapons, or other sharp objects are not allowed.Products containing alcohol are not allowed (for example, cologne and mouthwash). No aerosol products of any type are allowed. Lewd, revealing, or pornographic materials are not allowed. This includes photos, posters, magazines, or movies (for example, X-rated videos/DVDs). Clothing or any article depicting offensive statements or alcohol/drugs is not allowed, including gang-associated clothing (“colors”) such as hairnets, bandanas, and doo-rags. Clients may not use any over-the-counter medications (OTCs) other than those available at the facility or with a Physician’s Standing Order for OTCs. No outside food (candy, gum, soda, fast food, other snack items, etc.). No jewelry or body piercing items.No pens, pencils, markers, or notebooks (these will be provided as necessary).No hair grooming items (aerosol, gel, grease, mousse, Vaseline, hairspray, dryer, picks, curling iron etc.). No tank tops, undershirts, cut-off t-shirts (sleeves or belly), mesh shirts (see-through), skinny jeans, or short skirts. No steel toe boots or any type of metal sole shoes. We look forward to meeting and working with you and your family. Thank you for your interest and support.-Staff at RMCHCS Residential Treatment CenterConsent to Release/Exchange InformationClient Name __________________________________ Pt. ID ______________________ DOB ____________________4924425255905650 Vandenbosch Parkway, Gallup, NM 8730100650 Vandenbosch Parkway, Gallup, NM 87301I hereby request and authorize ______________RMCHCS SAT C – East Campus , _______________ ___(Name and Location of Clinician/Clinic)To release/exchange (circle one) with __________________________________________________________________(Name and Location of Person/Organization)The following information from my records:________ Assessment Results________ Treatment Summary________ Other (Specify): ____________________________________________________________________________The purpose of the disclosure authorized herein is: __________________________________________________________________________________________________(Purpose of Disclosure, as Specific as Possible)I understand that my records are protected under HIPAA and other Federal Regulations governing confidentiality (42 CFR Part 2), and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:__________________________________________________________________________________________________(Specification of the date, event, or condition upon which this consent expires)_____________________________________________________________________________________Signature of Client Date_____________________________________________________________________________________Signature of Staff DateRMCHCS Substance Abuse Treatment Center650 Vanden Bosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778LETTER OF COMMITMENT TO ADMISSION AND TREATMENTClient Name: ______________________________________________________ DOB: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature of Client: _____________________________________________________ Date: ______________________RMCHCS Substance Abuse Treatment Center650 Vanden Bosch ParkwayGallup, NM 87301Office: 505-726-6919 Fax: 505-726-6778Forms must be complete prior to potential review by clinical admission team.Incomplete forms will delay the admission process.CONTACT INFORMATION OF REFERRING AGENCYName/Title and Agency: ________________________________________________________________________________________________________________________________________________________________________________Address: _______________________________________ City/State/Zip: ______________________________________Phone: ________________________________________ Fax: _______________________________________________PERSONAL DATA (Completed by Applicant)Date of Application: ______________________________ Referral: Voluntary? Yes No Name: _________________________________________ Home Phone: _______________________________________Address: _______________________________________ Cell Phone: _________________________________________City: __________________________ State: __________ Zip Code: __________________________________________Birthdate: _____________________ Age: ____________ Gender: ______________ Race/Ethnicity: ________________Social Security #: ________________________________ Primary Language: ___________________________________CIB (if applicable): Enclosed? Yes No Religion (optional):____________________________________EMERGENCY CONTACT INSURANCE INFORMATIONName: ________________________________________ Type of Insurance: ____________________________________Relationship: ___________________________________ Address: ____________________________________________Address: ______________________________________ Policy # / Group #: ____________________________________Phone: ________________________________________ Medicaid Medicare Medicaid/Medicare ID #: ______________________________PRESENTING PROBLEM1. Have you ever felt the need to Cut Down on your drinking/use of drugs? Y N2. Have you been Annoyed by the criticism of others about your drinking/drug use? Y N3. Have you felt Guilty about the amount of drinking you do? Y N4. Have you ever had an Eye Opener (drink) first thing in the morning, to steady your nerves? Y N5. In the last 30 days have you experienced any of the following symptoms (check all that apply)? Mood Disturbance Hopeless/Helpless Sleep Disturbances Fatigue/No Energy Poor Memory Increased Anxiety Increased Appetite Decreased Appetite Lack of Motivation Lack of Interest Thoughts of Dying Feelings of Guilt Irritability/Anger Impulsivity Too Much Energy Feelings of Worthlessness Hearing Things Seeing Things Psychosis Present Inability to ConcentratePERSONAL, FAMILY, AND RELATIONSHIPS1. Who is in your family (parents, brothers, sisters, children, etc.)? _____________________________________________________________________________________________________________________________________________2. Where do you live? _______________________________________________________________________________3. How are the relationships in your family (good, fair, poor, close, etc.)? ______________________________________4. Who is your positive support system (friends, extended family, etc.)? _______________________________________5. What is your current marital status? __________________________________________________________________6. Do you have any children? If so, how many? ___________________________________________________________EDUCATION1. What is the highest grade you completed in school? _____________________________________________________2. Are you able to read and write? _____________________________________________________________________WORK1. Employment status: Full-Time Part-Time Unemployed Self-Employed2. Income source: Wage/Salary Public Assistance Family Other3. Military Service: Yes No Branch and Dates: _____________________ Discharge Status: ______________LEGAL1. Have you ever been arrested? If so, please provide details on the date(s), how many times you have been arrested, and in what court (tribal, county, magistrate, etc.) ___________________________________________________________________________________________________________________________________________________________2. Are you on State or Federal Probation/Parole? Yes No Name of PO: ________________________________Address: _____________________________________________ City/State/Zip: ________________________________Phone: ______________________________________________ Fax: _________________________________________4. Have you ever been arrested or charged with a sexual offense? ___________________________________________5. Are you awaiting a court date or currently incarcerated for a sexual offense? _________________________________6. If so, are you receiving sex offender counseling (agency/location)? _________________________________________TOBACCO HISTORY1. Do you use tobacco (cigarettes, snuff, etc.)? Yes No2. What forms of tobacco are you using (check all that applies)? Cigarettes Cigars Chewing Tobacco Other3. How many times on an average day do you use tobacco? _________________________________________________ALCOHOL/DRUG USE HISTORYLongest period of sobriety: ____________________________________________________________________________Please indicate history of alcohol/drugs below:SubstanceAge First UsedAmount Used CurrentlyFrequency of Use (How Often)Date of Last UseAre there any current physical illnesses, chronic medical conditions, or disabilities that may complicate treatment? Please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________Have you ever been diagnosed with Traumatic Brain Injury (TBI)? If so, please explain:__________________________________________________________________________________________________WITHDRAWAL SYMPTOMS: Tremors Seizures/DTs Hallucinations None Cramping Sweating Nausea/Vomiting AgitationHISTORICAL ISSUES: Adult Child of an Alcoholic History of Childhood Abuse Unresolved Grief Issues Attended Boarding School Family on Relocation Abuse/Violence in Home of Origin OtherPlease explain: ________________________________________________________________________________________________________________________________________________________________________________________Applicant’s Self-Identified Strengths: ______________________________________________________________________________________________________________________________________________________________________Past or Current Treatment History for Substance Abuse/Chemical Dependency ServicesDateInpatient or OutpatientLength of StayFacility/LocationMEDICATIONS Yes NoPrimary Health Provider: _______________________________Name of MedicationDosage (mg per day)Reason for MedicationNOTE: A medical clearance is required to complete the application for treatment center admission. ADDITIONAL HEALTH/DENTAL QUESTIONS:Do you have any pending medical or dental appointments? YES NOIf yes, please explain (appointments must be rescheduled or taken care of prior to admission): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Guidelines for Using the Mental Health Screening Form IIIThe Mental Health Screening Form-III (MHSF-III) was initially designed as a rough screening device for clients seeking admission to substance abuse treatment programs. Each MHSF-III question is answered either “yes” or “no.” All questions reflect the respondent’s entirelife history; therefore all questions begin with the phrase “Have you ever...”The preferred mode of administration is for staff members to read each item to the respondent and gettheir “yes” and “no” responses. Then, after completing all 18 questions (question 6 has two parts), the staffmember should inquire about any “yes” response by asking “When did this problem first develop?”; “Howlong did it last?”; “Did the problem develop before, during, or after you started using substances?”; and,“What was happening in your life at that time?” This information can be written below each item in the spaceprovided. There is additional space for staff member comments at the bottom of the form.The MHSF-III can also be given directly to clients for them to complete, providing they have sufficientreading skills. If there is any doubt about someone’s reading ability, have the client read the MHSF-IIinstructions and question number one to the staff member monitoring this process. If the client can not readand/or comprehend the questions, the questions must be read and/or explained to him/her.Whether the MHSF-III is read to a client or s/he reads the questions and responds on his/her own, thecompleted MHSF-III should be carefully reviewed by a staff member to determine how best to use theinformation. It is strongly recommended that a qualified mental health specialist be consulted about any“yes” response to questions 3 through 17. The mental health specialist will determine whether or not a followup,face-to-face interview is needed for a diagnosis and/or treatment recommendation.The MHSF-III features a “Total Score” line to reflect the total number of “yes” responses. Themaximum score on the MHSF-III is 18 (question 6 has two parts). This feature will permit programs to doresearch and program evaluation on the mental health-chemical dependence interface for their clients.The first four questions on the MHSF-III are not unique to any particular diagnosis; however, questions5 through 17 reflect symptoms associated with the following diagnoses/diagnostic categories: Q5,Schizophrenia; Q6, Depressive Disorders; Q7, Post-Traumatic Stress Disorder; Q8, Phobias; Q9, IntermittentExplosive Disorder; Q10, Delusional Disorder; Q11, Sexual and Gender Identity Disorders; 12Q EatingDisorders (Anorexia, Bulimia); Q13 Manic Episode; Q14 Panic Disorder; Q15 Obsessive-Compulsive Disorder;Q16 Pathological Gambling; Q17 Learning Disorder and Mental Retardation.The relationship between the diagnoses/diagnostic categories and the above cited questions wasinvestigated by having four mental health specialists independently “select the one MHSF-III question that bestmatched a list of diagnoses/diagnostic categories.” All of the mental health specialists matched the questionsand diagnoses/diagnostic categories in the same manner, that is, as we have noted in the preceding paragraph.A “yes” response to any of questions 5 through 17 does not, by itself, insure that a mental healthproblems exists at this time. A “yes” response raises only the possibility of a current problem, which is why aconsult with a mental health specialist is strongly recommended J.F.X. Carroll, Ph.D. & John J. McGinley, M.S., M.S.W., M.A. ? 4/2000 by Project Return Foundation, Inc.This material may be reproduced or copied, in entirety, without permission. Citation of the source is appreciated.MENTAL HEALTH SCREENING FORMInstructions: In this program, we help people with all of their problems, not just their addictions. This commitment includes helping people with emotional problems. Our staff is ready to help you deal with any emotional problems you may have, but we can only do this if we are aware of the problems. Any information you provide to us on this form will be kept in strict confidence. It will not be released to any outside person or agency without your permission. Please note that each item refers to your entire life history, not just current situation. This is why each question begins with, “Have you ever…”Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about emotional problems?YESNOHave you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems?YESNOHave you ever been advised to take medication for anxiety, depression, hearing voices, or for any emotional problems?YESNOHave you ever been seen in a psychiatric emergency room or been hospitalized for a psychiatric reason?YESNOHave you ever heard voices no one else could hear, or see objects or things which others could not see?YESNOHave you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself?YESNOHave you ever attempted to kill yourself?YESNOHave you ever had nightmares or flashbacks as a result of being involved in some taumatic/terrible event (for example, warfare, gang fight, fire, domestic violence, rape, incest, car accident, being shot or stabbed)?YESNOHave you ever experienced any strong fears (for example, fear of heights, insects, animals, dirt, attending social events, being in a crowd, being alone, being in a place where it may be hard to escape or get help)?YESNOHave you ever given in to an aggressive urge or impulse, on more than one occasion, which resulted in serious harm to others or led to the destruction of property?YESNOHave you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior?YESNOHave you ever experienced any emotional problems associated with your sexual interests, your sexual activities, or your choice of sexual partner?YESNOWas there ever a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling you’re eating (for example, by repeatedly dieting or fasting, engaging in a great deal of exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up?YESNOHave you ever had a period of time when you were so full of energy and your ideas came very rapidly, talked nearly non-stop, moved quickly from one activity to another, needed little sleep, and believed you could do almost anything?YESNOHave you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you were going to faint?YESNOHave you ever had a persistent, lasting thought or impulse to do something over and over that caused you considerable distress and interfered with normal routines, work, or your social relationships? Examples would include repeatedly counting things, checking and rechecking things you have done, washing and rewashing your hands, or maintaining a very rigid schedule of daily activities from which you could not deviate?YESNOHave you ever lost a considerable sum of money through gambling or had a problem at work, in school, or with your family/friends as a result of your gambling?YESNOHave you ever been told by a teacher, guidance counselor, or other individual that you have a special learning problem?YESNOPrint Client’s Name: ___________________________________________________________________Program to which client will be assigned: ___________________________________________________Name of Admissions Counselor: ______________________________________ Date: ______________Reviewer's Comments: ___________________________________________________________________________________________________________________________________________________Total Score: __________ (each yes = 1 pt.)7810501133475NAME:DATE:00NAME:DATE:9340851491615Over the last 2 weeks, how often have you beenOver the last 2 weeks, how often have you been2725945824865PATIENT HEALTH QUESTIONNAIRE (PHQ-9)PATIENT HEALTH QUESTIONNAIRE (PHQ-9)10052051671320bothered by any of the following problems?bothered by any of the following problems?10096501590675(use "?" to indicate your answer)Not at all1.Little interest or pleasure in doing things01232.Feeling down, depressed, or hopeless01233.Trouble falling or staying asleep, or sleeping too much01234.Feeling tired or having little energy01235.Poor appetite or overeating0123have let yourself or your family down6.Feeling bad about yourself or that you are a failure or0123newspaper or watching television7.Trouble concentrating on things, such as reading the0123have noticed. Or the oppositebeing so figety or0123restless that you have been moving around a lot morehurting yourself9.Thoughts that you would be better off dead, or of012300(use "?" to indicate your answer)Not at all1.Little interest or pleasure in doing things01232.Feeling down, depressed, or hopeless01233.Trouble falling or staying asleep, or sleeping too much01234.Feeling tired or having little energy01235.Poor appetite or overeating0123have let yourself or your family down6.Feeling bad about yourself or that you are a failure or0123newspaper or watching television7.Trouble concentrating on things, such as reading the0123have noticed. Or the oppositebeing so figety or0123restless that you have been moving around a lot morehurting yourself9.Thoughts that you would be better off dead, or of012353422551701165SeveraldaysSeveraldays67360801736868Nearlyevery dayNearlyevery day60050331628140More thanhalf thedaysMore thanhalf thedays100888757615748.Moving or speaking so slowly that other people could8.Moving or speaking so slowly that other people could11430006404702than usualthan usual43952157406641add columns++add columns++667511874066415212078777240111879537751200(Healthcare professional: For interpretation of TOTAL,TOTAL:please refer to accompanying scoring card).00(Healthcare professional: For interpretation of TOTAL,TOTAL:please refer to accompanying scoring card).10572758020050your work, take care of things at home, or getalong with other people?10. If you checked off any problems, how difficultNot difficult at allhave these problems made it for you to doSomewhat difficultVery difficultExtremely difficult00your work, take care of things at home, or getalong with other people?10. If you checked off any problems, how difficultNot difficult at allhave these problems made it for you to doSomewhat difficultVery difficultExtremely difficult9182109626600A2663B 10-04-2005A2663B 10-04-20056985009459595Copyright ' 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD' is a trademark of Pfizer Inc.Copyright ' 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD' is a trademark of Pfizer Inc.PHQ-9 Patient Depression QuestionnaireFor initial diagnosis:1. Patient completes PHQ-9 Quick Depression Assessment.2. If there are at least 4 s in the shaded section (including Questions #1 and #2), consider a depressivedisorder. Add score to determine severity.Consider Major Depressive Disorder- if there are at least 5 s in the shaded section (one of which corresponds to Question #1 or #2)Consider Other Depressive Disorder- if there are 2-4 s in the shaded section (one of which corresponds to Question #1 or #2)Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician,and a definitive diagnosis is made on clinical grounds taking into account how well the patient understoodthe questionnaire, as well as other relevant information from the patient.Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, ahistory of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as thebiological cause of the depressive symptoms.To monitor severity over time for newly diagnosed patients or patients in current treatment fordepression:1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) athome and bring them in at their next appointment for scoring or they may complete thequestionnaire during each scheduled appointment.2. Add up s by column. For every : Several days = 1 More than half the days = 2 Nearly every day = 33. Add together column scores to get a TOTAL score.4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree ofresponse, as well as guiding treatment intervention.Scoring: add up all checked boxes on PHQ-9For every Not at all = 0; Several days = 1;More than half the days = 2; Nearly every day = 3Interpretation of Total Score Total ScoreDepression Severity14 Minimal depression59 Mild depression1014 Moderate depression1519 Moderately severe depression2027 Severe depressionPHQ9 Copyright ? Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ? is atrademark of Pfizer Inc.A2662B 10-04-2005ASAM Severity Profile (Clinician Must Fill Out)Checkmark: (0 = no problem or stable / 1 = mild / 2 = moderate / 3 = substantial / 4 = severe)Dimension I: Acute Intoxication/Withdrawal Potential0 ___ Fully functioning with good ability to tolerate or cope with withdrawal discomfort.1 ___ Adequate ability to tolerate or cope with withdrawal discomfort2 ___ Some difficulty tolerating and coping with withdrawal discomfort.3 ___ Severe signs and symptoms or risk of severe but manageable withdrawal.4 ___ Continued use poses an imminent threat to life.Dimension II: Biomedical Conditions and Complications0 ___ No biomedical conditions that will interfere with treatment or create risk.1 ___ Mild to moderate signs interfere with daily functioning, but would not likely interfere with recovery treatment.2 ___ Has a biomedical problem which may interfere with recovery treatment.3 ___ Severe medical problems are present requiring medical or nursing services. 4 ___ Incapacitated, with severe medical problems. Dimension III: Emotional/Behavioral/Cognitive Conditions and Complications0 ___ No mental health problems.1 ___ Mild to moderate signs and symptoms with good response to treatment in the past. 2 ___ Emotional, behavioral, or cognitive problems distract from recovery efforts. 3 ___ Frequent impulses to harm self or others which are potentially destabilizing, but not imminently dangerous.4 ___ Individual has severe, unstable psychiatric symptoms and requires secure confinement. Dimension IV: Readiness to Change0 ___ Can articulate personal recovery goals. In Preparation or Action Stage of Change.1 ___ Willing to explore need for treatment and strategies to reduce/stop substance abuse.2 ___ Reluctant to agree to treatment for chemical dependency problems but willing to be compliant to avoid negative consequences or legally required to engage in treatment.3 ___ Appears unaware of any need to change and unwilling or only partially able to follow through with treatment recommendations4 ___ Not willing to explore change and is in denial regarding addiction and its implications. Dimension V: Relapse, Continued Use, Continued Problem Potential0 ___ Low relapse or continued use, appropriate level of coping skills.1 ___ Fair self-management and relapse prevention skills.2 ___ Difficulty maintaining abstinence despite engagement in treatment.3 ___ Frequent use of alcohol/drugs (3 or more times per week).4 ___ No skills to cope with or interrupt addiction(s) to prevent/limit relapse or continued use. Dimension VI: Recovery Environment0 ___ Living in a dry, alcohol/drug-free home.1 ___ Subcultural norms discourage abusive use.2 ___ Ready access to alcohol and drugs near home.3 ___ Subcultural norms encourage abusive use.4 ___ Environment is hostile and toxic to recovery or treatment progress. CLINICIAN SIGNATURE:_____________________________MEDICAL SCREENING/ADMISSION H&PDate of Exam: _________ Chief Complaint/Seeking treatment for: Substance misuse disorder Other:_____________ LAST ETOH/DRUG USE: _______________________________________________________________________________Height: ______________ Weight: _________________ B/P: _____________________ Pulse: ___________________MEDICAL PROBLEM LIST (by acuity): _____________________________________________________________CURRENT MEDICATIONS:______________________________________________________________________________________________________________________________________________________________________Physical ExamLABSRESULTDATEGeneral/affect: Hepatitis BLungs/breathing: Hepatitis CHeart/rhythm:HIV Abdomen/bowels:RPRExtremities/ambulation/amputations: GonorrheaSkin conditions/scars/wounds:ChlamydiaNeurologic deficits:Tuberculin Skin TestAdditional labs: A1C, CBC CMP, Thiamine, Folate, Urine HCG (Female Only )Allergies: Medications/Food: ________________________ Diet: Regular or Other: _____________________________Stability: Medically stable to participate in residential treatment and group therapy: Yes NoMedically stable to participate in group physical activities (1 mile walk, volleyball, etc.): Yes NoMedically stable to participate in traditional sweat lodge: Yes NoPhysically able to climb on/off bunk bed? Yes NoNotes/Restrictions: _________________________________________________________________________________Client Name: ________________________________________________________ DOB: ________________________Provider Name (print): ______________________________ Degree: _______ Provider Signature:______________________ Clinic Name & Address: _______________________________________________________________________________MEDICATION ORDERS(Any Prescribed/Over-the-Counter Medication Self-Administration)Client Name: ____________________________________________ DOB: ____________________________________RMCHCS Substance Abuse Treatment Center is licensed by the New Mexico Board of Pharmacy to provide assistance to clients with self-administration of medications. We are required to obtain an order for medication from a Licensed Practitioner in order to adhere to all self-administration regulations. This Standing Order pertaining to this client will remain in effect for the duration of the client’s stay at RMCHCS Substance Abuse Treatment Center. We provide limited “over-the-counter” symptomatic relief medications. These OTC’s are provided for temporary relief of self-limiting symptoms. Clients will seek medical attention when appropriate, for example if there appears to be a sensitivity reaction, significant side effects, or when relief is not obtained within a reasonable time frame. PLEASE WRITE OUT A DETAILED ORDER WHICH INCLUDES:1. Medication2. Symptoms being treated3. An exact dose4. A maximum total dose per 24 hoursPLEASE INDICATE THE FOLLOWING:KNOWN ALLERGIES: _________________________________________________________WHETHER THE INDIVIDUAL IS NOT TO USE ANY OF THE OTC’S PROVIDED AND THE REASON?Please Check and/or Notate Below:1. Acetaminophen 325mg / Tylenol 325mg by mouth 1 to 2 tablets every 6 hours as needed for pain or fever.2. MAG-AL-PLUS XS (Maalox) take 30ml by mouth as needed for GI upset. Do not exceed 60ml in a 24 hour period. ____________________________________________________________________________________________________________________________________________________________________________________________________Signature of Licensed Practitioner: ____________________________________________________ Date: ____________ ................
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