RFP_Attachment_18_-_Franco-Gonzalez_Health_Form.docx

Attachment 18 - Franco-Gonzalez Health Form 13-61A-1 CMHE Follow up Screening-ICE Detainees Facility:

Inmate/Resident Name: _______________________________ Date of Evaluation: _________ Inmate/Resident No.: _________________________________ Date of Birth: _____________ This form is to be completed for any detainee who had "Yes" answers on the Initial Comprehensive Mental Health Evaluation. Any item marked by an asterisk (*) indicates a trigger for additional mental health assessment and/or follow up.

SECTION 1: BARRIERS TO COMMUNICATION-provider to enter "Y" or "N" for observed problems in each of the categories.

1. *Hearing

2. *Forming Speech

3. *Comprehension

4. *Lack of Response

5. *Response not Logical

6. *Other Problems: (List):

7. Communication Intact with No Barriers

Questions

In the last month, how much difficulty did you have concentrating on something for 10 minutes?

□None □Some □Severe

In the last month, how much difficulty did you have starting and maintaining a conversation?

□None □Some □Severe

SECTION 2: GAUGE OF UNDERSTANDING OF SITUATION-Recommended behaviorally cut-offs for scoring on a 1-10 scale: Understanding or Not Understanding, with a potential threshold of 5 or less. Asterisk (*) is trigger for additional mental health assessment and/or treatment.

YES NO

1. What is your understanding of your situation?

Identifies immigration detention facility?

If N: What kind of facility is this?

If N: Are you here for criminal or immigration court?

2. What might happen to you?

Identifies immigration court hearing?

Identifies potential for deportation?

3. Who can help you?

Identifies realistic resources?

4. How can you communicate with people outside of the facility?

Identifies how to access outside resources?

SCORING:

How well did the detainee demonstrate an understanding of his/her situation?

□1= No understanding of detainee status. Did not mention immigration or any relevant process or has erroneous beliefs. * □5=Limited understanding. * □10=Perfect understanding of detainee status. Described immigration processes and resources with accuracy and specific detail.

SECTION 3: COGNITIVE IMPAIRMENTS-Asterisk (*) is trigger for additional MH assessment and/or treatment.

Memory Functioning:

Register & recall 3 words after 3-minute delay: detainee repeated ____of the 3 words. If "N"*

In the last month, did you have problems remembering to do important things?

If Yes, Describe:

Intellectual functioning

How far did you get in school? Response:

Can you read? If "N" *

Did you learn more slowly than your classmates? If "Y" *

If Y: Were in Special Education classes or a special School? *

If Y: What years of school were you in special Education: Response:

Have you ever lived alone?

Describe your longest job.

Cognitive impairment from head injury

Have you ever had a head injury or head surgery?

If Y*: Was there any change in thinking or memory?

SECTION 4: SOCIAL HISTORY (not otherwise covered by existing questions, i.e., relationships & cultural concerns)

Marital status and family history:

Do you have a history of violence?

If so, were you the victim or the perpetrator?

Do you have a criminal history?

Do you have a history of alcohol abuse or dependence?

Do you have a history of drug abuse or dependence?

Do you have a history of physical abuse?

Do you have a history of sexual abuse?

Who are the most important people in your life?

What is the most important aspect of your background or identity?

SECTION 5: HISTORY OF MEDICAL/MENTAL HEALTH TREATMENT- Asterisk (*) is trigger for additional mental health assessment and/or treatment.

ARE YOU EXPERIENCING ANY MEDICAL ISSUES OR COMPLAINTS?

IF YES RESPONSE, REFERRAL TO HEALTH SERVICES/NURSING.

DO ANY OF YOUR IMMEDIATE FAMILY MEMBERS HAVCE A HISOTRY OF ANY MEDICAL ISSUES? (IF YES, LIST)

Do you currently take any medications?

If "N": Have you ever been prescribed medication for mental health needs?

Have you ever seen a mental health doctor or counselor?

If "Y"*: Year: ________. Associated symptoms:

Key diagnoses for further referral: bipolar disorder/schizophrenia/suicidality/schizoaffective DO

Does have your family have a history of mental illness?

Have you ever been in a hospital for mental health problems?

If "Y"*: Year: ______. Associated symptoms/diagnosis:

Key diagnoses for further referral: psychotic symptoms, depression, mania, bipolar

If yes to any of the questions: (provider responses only)

List attempts to contact prior facilities providers or family:

List any new information obtained:

SECTION 6: SUICIDAL IDEATION & SELF HARM- Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Have you ever made a suicide attempt? If "Y"*: Number of attempts: Year(s):

Do you have a past or present history of self-inflicted cutting?

Are you having suicidal thoughts now? If "Y"*: Plans/means/intent:

Have you ever harmed or hurt yourself on purpose? If "Y"*

Are you having thoughts or urges to do that here?

SECTION 7: HALLUCINATIONS/DELUSIONS/PARANOIA-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Do you hear things that other people do not hear such as voices? If "Y"*-What do you hear:

Do you see things other people do not see such as visions? If "Y"*: What do you see:

Do you currently believe that someone can control your mind? If "Y"*

Do you think anyone is trying to harm you in any way? If "Y": What do you think is happening:

*If evidence of paranoia or bizarre beliefs

SECTION 8: DEPRESSION-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Do you feel sad or depressed? If "Y" – continue below

If "Y"*: Have you gained or lost as much as two pounds in the last few weeks without trying?

If "Y"*: Do you feel useless or sinful?

If "Y"*: Do you feel hopeless?

SECTION 9: MANIA-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Do you need less sleep than usual? If "Y"-continue below:

If "Y": Do you have extra energy?

If "Y": Do you talk all of the time?

If "Y"*: Do you have special powers?

If "Y"*: Do you have rapid or pressured speech?

SECTION 10: ANXIETY-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Have you ever experienced or witnessed something really terrible?

If “Y”: Do you have disturbing memories of the event?

If “Y”: Do you feel upset when something reminds you of the event?

Do you feel fearful? If "Y"-continue below

If "Y": Are you able to focus on things other than your anxiety?

If "Y"*: When you feel fearful do you have trouble breathing?

If "Y"*: When you feel fearful do you feel faint?

If "Y": Do you avoid situations that worry you?

SECTION 11: IMPULSIVITY-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Do you do things without thinking?

If "Y": Example:

Provider Observation related to impulsivity

Interrupts

Blurts out responses

Sudden movements

Gets out of chair

If "Y"*: Does behavior interfere with communication?

SECTION 12: OTHER BEHAVIORS RELATED TO CLASS MEMBERSHIP-Descriptions are keyed to behavioral definitions. All prompts are Y/N. If a response is "Y", a narrative description is needed. Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Repetitive or unusual movements? If "Y:*: Describe:

Responding to internal stimuli, such as voices or paranoid thoughts? If "Y"*: Describe:

Slowed or disjointed thoughts? If "Y"*: Describe:

Restless or distracted behavior? If "Y": Describe:

Sad or worried appearance? If "Y", Describe:

Poor understanding of questions? If "Y"*: Describe:

Delayed or non-responsive to some questions? If "Y"*, Describe:

Rapid and hard to interrupt speech? If "Y"*, Describe:

Childlike speech, demeanor or behavior? If "Y": Describe:

Sleep or appetite problems? If "Y": Describe:

SECTION 13: INCREASE SPECIFICTY, OBJECTIVITY AND DESCRIPTIONS FOR MHA MENTAL STATUS EXAM-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Provider Observations:

Grooming: □Low: disheveled, strong body odor

□High: neatly styled hair, excellent hygiene

Behavior:

Cooperation: □low (refusal to answer questions, argues over exam)

□moderate (inconsistent effort in answering questions)

□high (helpful & cooperative)

Activity: □low (slowed or minimal movement, non-spontaneous)

□moderate (spontaneous movement, stays seated)

□high (constant movement, leaves chair)*

Attention:

□low (distracted throughout assessment, frequently asked for repeated questions)

□moderate (loses track of questions one or two times during assessment)

□high (focused attention to all questions)

Orientation: Month: _____ Date: _____ Year:____ Facility: __________ Situation: ________ If lack of orientation to year or situation*

Affect:

Depressed

Anxious

Labile

Angry

Elevated

Euphoric

Suspicious

Congruent with mood state

Disorganized (* if Y)

Bizarre (* if Y)

Grimacing (* if Y)

Flat

Mood

What word describes your mood right now? Response:

On a scale of 1-10, with 1 being the worse mood and 10 being the best mood, what number describes your mood? Response:

Thought Process (provider observation)

Logical

Goal Oriented

Loosened

Rambling

Over-inclusive

Disjointed (* if Y)

Repetitive

Tangential (* if Y)

Disorganized (* if Y)

Word Salad (* if Y)

Flight of ideas (* if Y)

Clanging (* if Y)

Thought content (provider Observations)

Preoccupations -if Y: Describe:

Grandiosity (* if Y)

Paranoia (* if Y)

Bizarre Thoughts-if Y*-Describe

Nihilism (* if Y)

Do you have special connections or Abilities? * if Y. Describe:

Is

Is there anyone trying to harm you or your family: If Y, describe:

Is anyone controlling your thoughts or actions? * if Y. Describe:

SECTION 14: PERCEPTIONS-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

Do you have the following:

Auditory hallucinations (hearing things)-* if Y. Describe:

Visual hallucinations (seeing things)-* if Y. Describe:

Somatic/Tactile hallucinations (sensations within or on your body)-* if Y. Describe:

Olfactory hallucinations (smelling things)-* if Y. Describe:

Do you ever hear whispers? (Illusion)

Do you ever see shadows? (Illusion)

SECTION 15: FUTURE ORIENTATION AND INSIGHT-Asterisk (*) is trigger for additional mental health assessment and/or treatment.

What do you think is going to happen to you? Response:

SECTION 16: OTHER

Any other observations that indicate:

Mental illness, If Y: Describe

Cognitive disorder, If Y: Describe:

Class Membership, If Y: Describe:

SECTION 17: Include the following:

Does this person meet criteria for Franco Class Membership?

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