Free 47179.pdf - Indiana

INDIANA PASRR PROGRAM SCREEN FOR DEPRESSION (Use to Determine If a Person Needs to be Referred for PASRR/MI Level II Assessment)
State Form 47179 (R/7-98) / BAIS 0026 SOCIAL SECURITY NUMBER

*Your Social Security number is requested in See instructions on the reverse side.
Name of individual Social Security number * Date of Birth

accordance with IC 4-1-8; however disclosure is not mandatory.

PRIVACY NOTICE THIS FORM IS CONFIDENTIAL PER IC 4-1-8

FOR IPAS AGENCY USE ONLY
Not required for all persons with depression. Only complete the following questionnaire in situations when there is a question of whether a diagnosis or condition of "depression" is of a duration or intensity sufficient to require PASRR / MI Level II assessment. Completion of this form will help document the referral decision. When it is completed, this form must be made part of the IPAS / PASRR case record and maintained on the NF active record. Use the suggested questions included below, but the assessor is not limited to these questions. Whether the condition of depression requires Level II assessment is determined not by the situation or terminology used, but by the depression's duration and / or level of intensity. Use of the terms "situational" or "reactive" depression are often misleading. Depression due to a general medical condition or resulting from grieving may be related to the thought of having to give up one's home and / or independent life-style ("pre-grieving") and / or may be related to the loss of a loved one or of one's physical well-being. Questions should be directed to your CMHC PASRR contact person, and the contact information, including response,recorded below. Some situations require a judgment call by the IPAS screener. This Depression Screen provides some guidance, but is not intended to be the sole determinant. NOTE: Cases using this form, regardless of results, must be handled as a PASRR case and submitted to the State PASRR Unit for final determination. 1. The person experiences recurrent thoughts of death (not just a fear of dying) or suicidal thoughts (regardless of intention to carry it out). (Do you have thoughts of killing yourself?) Yes No

A "Yes" answer to #1 always requires referral for Level II as soon as possible.
2. The person experiences a depressed mood most of the day, nearly every day. (What is your mood today? Have you been feeling sad, blue, down, or depressed? For how long? How bad is the feeling?) 3. The person experiences markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day. (What do you normally enjoy doing? What do you still enjoy? Do you enjoy them as much as usual?) 4. The person has experienced a marked change in appetite. (Is your appetite different than usual? In what way? For how long?) Yes No

Yes

No

Yes

No

5. The person has experienced significant weight loss when not dieting or significant weight gain in the past month. (Have you lost weight or gained weight lately? How much? Why?) 6. The person has experienced a significant change in sleeping patterns. (Has there been a change in your sleep patterns? When did this change start? How often does it occur?) 7. The person complains about a significant change in energy level. (Do you get unusually tired or worn out? Explain)

Yes

No

Yes

No

Yes

No

8. The person experiences feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt about being sick). (How do you feel about yourself lately? Do you feel worthless or a failure? How long have you felt this way?) 9. The person experiences a diminished ability to think or concentrate or experiences indecisiveness. (Are you having more difficulty than usual concentrating on your activities? Making every day decisions?) Duration of symptoms: 30 days 60 days 90 days More than 90 days

Yes

No

Yes

No

A"Yes" response to any two (2) of Questions #2-#9 is an indication for a referral for a PASRR / MI Level II assessment.
ADDITIONAL COMMENTS / SUMMARY

DETERMINATION: Yes, PASRR / MI Level II needed.
Information provided by:

No, PASRR / MI Level II not needed. (If No, include on PAS 4A and 4B the caveat from the back of this form.)
Relationship to applicant:

Signature and printed name of person completing protocol:

T elephone number

IPAS Agency number:

Date:

SCREEN FOR DEPRESSION INSTRUCTIONS FOR IPAS AGENCY USE ONLY Purpose: The diagnosis of "Depression" is widely used to describe various conditions ranging from "anxiety" to "major depression". The judgment of whether there is a need for Level II assessment based on a diagnosis of depression may be clear and easy to make, or it may require greater investigation by the entity responsible for making the referral for the Level II. Also the generic term, "situational depression", is often misapplied and may not clearly identify the condition. The "Depression Screen" is designed to assist the IPAS agency reviewer to make and document judgment calls for those situations in which the need for Level II is difficult to judge. 1. 2. 3. 4. Prior to the interview, review all available pertinent information. Ask questions as indicated. Additional questions may be asked as needed to elicit clarifications. Notations may be entered near the individual questions to help with reviewer recall. Based on the individual's responses, the reviewer will check "yes" or "no" for each question.

5. ALL questions must be answered. Do not stop the screening process partway through unless it is clearly documented on the form why the interview could not be completed. Refusal to respond to the questions would indicate that a Level II is needed. 6. Enter pertinent additional comments and/or a summary in the space provided. Use this space to alert the NF and/or the State PASRR Unit to areas which require special attention. 7. Enter the "Determination" of need for a Level II finding in the appropriate allotted space. 8. Enter the name(s) of the person(s) providing the information on which the Depression screen is based. State the relationship(s) of the person(s) supplying the information. 9. The evaluator MUST sign the form, print his or her name, and enter the number of the affiliated IPAS agency. This document must be dated with the date the screen was completed and the determination of need for Level II is made. 10. When the finding is that a Level II is not needed at this time, the following caveat should be entered on the PAS 4A form issued by the IPAS agency and on the PAS 4B form issued by the State determination entity ( State PASRR Unit):

"Level II is not completed at this time, although the above-named applicant's condition would ordinarily require PASRR Level II assessment. It is the responsibility of the NF to monitor the individual's condition. If the depressed condition, behavior, or mood either worsens or has not improved within 90 days following NF admission, the NF must make a referral to the local CMHC for a non-routine RR."
The NF is then responsible to monitor and assure a Level II referral is made when required. When completed, this form must always be made part of the IPAS case record.