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2Current Mental Health Status (Check all that apply) Alert, oriented x _______ Disoriented Reports Hallucinations Endorses Delusions <br />Grooming/ Hygiene Eye Contact Affect Mood Thought Process Speech Movement/Activity <br />to situation to situation to situation to situation Angry Cheerful Calm <br />to situation Logical Goal directed Disorganized <br />topic to topic quickly <br />to situation situation <br /> Aggressive DISPOSITIONAction Taken Initial Housing Recommendation <br /> Emergent/Urgent: Referred to the Shift Commander under Policy 315 Refer to Mental Health for follow up within 24 hours Refer to Mental Health for follow up within 72 hours Refer to Mental Health for follow up within 14 days if indicated following clinician review No need for Mental Health follow up - cleared <br /> Cleared for general housing placement Not cleared - referred for holding cell placement Other placement: <br />__________________________________________________ <br />__________________________________________________ Informed Consent I acknowledge that I have answered all questions truthfully and have been informed about how to obtain mental health services. I consent to routine mental health care provided by facility healthcare professionals. <br />Resident Signature:_____________________________________________________Date: ___________________________ Screener/ Reviewer Screened by: ___________ __________ ______________________________ Date Time _________________________ Printed Name/Title Signature <br />Screening Reviewed: _________ ________ __________________________ ______________________________ Date Time Printed Name/Title Clinician Signature <br /> MH Secondary Assessment Completed: ________ ________________________ _________________________ Date Printed Name/Title Signature Clinical Follow Up Follow Up SOAP Note/if indicated: <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />___________________________________________________________________________________________________ <br />_____________ ____________ ___________________________ ________________________________ Date Time Printed Name/Title Clinician Signature <br />Moving from <br />315.02.01.001 <br />(Form last updated 10/28/2016) <br />Mental Health Screening