Please Fax to Beacon Health Options:

Outpatient Review Form

800.441.2281 / 781.994.7634

Member information (Verify eligibility before rendering services)

Member name:

Kevin P Freund

10033779

Member ID#:

D.O.B:

11-21-1950

Provider information

Bleuler Psychotherapy Center

111840049
Provider ID#:
Provider / agency name:

Clinician name:
Phone number:

Jessica Nelson
7182756010

Request for sessions

I request

sessions, starting on:

11/17/16

over the next:

90 days

Other:

180 days

Current psychotropic medications

Are psychotropic meds being prescribed?
Prescriber:

Yes*

Unknown

No

Dr Joseph Cohen

*If Yes, prescribed by:

MD

RN

CS/NP

PCP

Celexa 40 mgs

List Meds:

Have you communicated with the members prescriber of psychotropic drugs?

Yes

No

Member declined

N/A; Member not on medications

Have you communicated with members PCP?

Yes

No

N/A; Provider is the prescriber

Member declined

Have you documented the communication or member declination?

Yes

No

N/A; I did not contact PCP

Have you been in communication with other BH providers for this member?
Yes (please specify):

authorizations

No

Member declined

N/A; There are no other BH providers

Site of treatment
Office

School

Home

Additional Comments:

Other (please specify):

MH OPD Center

ICD-10/DSM-5 diagnoses (Please give more than one diagnosis as necessary for clinical presentation.)
Diagnosis:

F33.1

Diagnosis:

F41.1

Diagnosis:

Diagnosis:

Current risk indicators (check all that apply):

Current substance abuse
Caring for ill family member
Current family violence
Fire setting
Impulsive behavior
Coping with significant loss
Prior Psychiatric Inpt. Admission

Self-mutilating / cutting
Assaultive behavior
Other (please specify):

Sexually offending behavior

Psychotic symptoms

Opoid Dependence (in Remission)

Status of 3 most significant objectives since treatment initiation (Please include additional page if space provided is insufficient.)
Objectives
1.
2.
3.

Estab. functioning baseline;Healthy Cognitive Func.

Process multiple losses; long-term impasses;dpndnc
RetainPermanentHousing&Advance stability

N = New Goal

1 = Much Worse

2 = Somewhat Worse

Modality

Progress

Individual
Individual
Individual

4
4
4/5

(Individual/Group)

(in measureable/behavioral detail)

3 = No Change

(Rating since Tx began; use scale below)

4 = Slight Improvement

5 = Much Improvement

Risk assessment (Check all that apply)

Suicidality:
Homicidality:

Not present

Ideation

Not present

Plan

Ideation

Rate members level of psychological distress:

Current risk of psychiatric hospitalization*:

Means

Plan

Means

1 (minimal)
1 (minimal)

Prior Attempt (please specify date):

Prior Attempt (please specify date):
2 (mild)

3* (moderate)

2 (mild)

*If 3 or higher, have you created/reviewed a crisis plan for this member?
*If yes does member have a copy?

Yes

4* (marked)

3* (moderate)

Yes*

4* (marked)
No

5* (severe)
5* (severe)

Member declined

No

Has the member been in higher level of care in the last 12 months?
Was a standard instrument used to evaluate treatment progress?

Yes
Yes*

No
No *If yes, name instrument(s):

Beacon Health Strategies, LLC is a Beacon Health Options company.

BPC tx plan

R = Resolved