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315.02.01.001 (Form last updated 10/28/2016) 1 <br />IDAHO DEPARTMENT OF CORRECTION <br />Mental Health Screening <br />Resident Name: IDOC #: DOB: Date of Report: <br />Intake/New Arrival Inter Institutional Transfer Restrictive Housing Current Risk Factors1.Did the transporting officer report any concerns? If so please explain:No <br />Immediately notify the shift commander2.Right now, do you have thoughts of hurting yourself?No <br />3. Do you have any immediate plans to hurt yourself?Describe:No <br />4.Right now, are you currently feeling hopeless about your future?No Refer to MH for follow up within 24 hrs 5. Right now, do you have any mental health symptoms or complaints?On a 1-10 scale with 1 being none at all and 10 being extremely serious; rate your symptoms.Describe symptoms:(If rated at “5” or above, refer for clinician follow-up) <br />No <br />6.Within the past year have you engaged in self-harm or attempted suicide?Date: ___________Means/Method:_______________________Intent:______________________No Suicide/Self Harm History No Refer to MH for follow up within 72 hoursPrior Emergent Treatment7.Within the last 24 months, have you had a mental health hospitalization or been placed on amental health observation/watch in a correctional facility ?Date: __________ Hospital/Facility: _____________________ Reason: _______________________Date: __________ Hospital/Facility: _____________________ Reason: _______________________ <br />No Medication9.Are you currently taking mental health medications?Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________ <br />No <br />10. Have you ever taken mental health medications in the past?Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________Name: ___________Dose/Freq:______Last dose: ______Pharm: _________Prescriber:__________ <br />No <br />No Follow up to occur within 14 days if indicated following clinician review. 8.Within the last 24 months, have you engaged in self-harm or attempted suicide? <br />Date: ___________Means/Method: _______________________Intent:______________________ <br />Date: ___________Means/Method: _______________________Intent:______________________ <br />11.Prior to 24 months ago, have you been hospitalized for mental health reasons? <br />Date: __________ Hospital/Facility: _____________________Reason: _______________________ <br />Date: __________ Hospital/Facility: _____________________Reason: _______________________ <br />12.Prior to 24 months ago, have you attempted suicide or engaged in self-harm? <br />Date: ___________Means/Method: _______________________Intent:______________________ <br />Date: ___________Means/Method: _______________________Intent:______________________ <br />13.Do you have a history of outpatient mental health treatment?Date: __________ Care Provider: _______________________Reason: _______________________Date: __________ Care Provider: _______________________Reason: _______________________Mental Health TreatmentNo Substance Use14.Have you ever used any type of substances:No <br /> What? First Used: Last Used: How Much? What? First Used: Last Used: How Much? <br />15.Is this your first time in prison? <br />16.Have any family members or significant persons in your life attempted or committed suicide? <br />17.Have you recently experienced a significant loss such as a death of a close family member or friend?No <br />18.Have you ever been arrested for a sex crime?No <br />19.Have you ever been a victim of sexual or physical abuse?No <br />In custody: <br />No Other contributing suicide risk factors 20.Have you had a head injury? Describe: No <br />21.Have you ever received special education services?No <br />22.Are you worried about something other than your current legal situation? Describe:No <br />23.Do you have a physical illness that is causing you distress or pain? Describe:No <br />No <br />In custody: <br />No