Free Opening Brief in Support - District Court of Delaware - Delaware

* _. Case 1:04-pcvjOO328-_SLFt Document 27-4 Filed O9/12/2005 Page 1 of 3
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' Mental Health Services FHM
Comprehensive Mental Health Evaluation °°““""°"“‘
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HEALTH HISTORY
1. History of psychotropic medications Yes I] •)!5
Current usage Yes I;] * No I
If so, list medications below:
Evidence of EPS - Yes ij No EI
2. History of psychiatric hospitalization Yes K] Nog .
A) Name of facility/provider
B) Date: Fr0m_..M.r"_M to._.M..L_ _ Requested Records? Yr-ssl;] Noi;]
3. History of outpatient mental health treatment Yesiil No N
A) Name of facility/provider `
B) Date: From to p Requested Records? Yesi;] Noi:]
·. History of violence: (check those that apply) Yes!] Noi;]
I] Behavior I] Threats
Cl Verbally Assualtive ¤Physically Assaultive
Comments: .
5. History of self-injurious behavior Yeslj No?
Comments;
6. History of head injury, trauma Yesi] NK!
Describe;
Comments: »
7. Length of time in jail: Years Months a- Days .
8. Previous Prison incarceration State: = Ulf a _ YesE\ Nom
p Requested records? Yes I] Noi;}
9. History of placement in any special education programs Yes iu;] No Kit
Unit: _
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Inmate Name: cfu HA ’ E4, » ` inmate Number: I q QL
Institution: ~ C _ C __ 0 {Lf
First Correctional Medical · Proprietary information. Confidential PMP Y *-7 "*

Case 1 :04-cv-00328-SLR Document 27-4 Filed 09/12/2005 Page 2 of 3 g .
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-( BE]-IAVIORAL OBSERVATIONS
. (Check all Relevant Categories) `
Q Aggressive D Irrational Q Passive
Agitated lj Labile D Withdrawn
Delusional E] Lethargic [§I`erriii ·
Eye Contact { D Loose Associa `ons ` ` , U Other:
Hallucinatin g Manipulative/'pssfnle s \* lr
Q Hyperactivity Paranoia
Comments;
MENTAL STATUS EXAMINATION _ N gg gg __ _ __ ____ w_____
e · · ‘‘‘i . ‘ ‘ ‘ i ‘(Writeiri BiiefDési:ii`i5ti6ii} `''` ```` " I l l -''' U N
` Concentration: intellectual Functioning:
Mm
I 'entationt Speech: ~
| there _
~ SUICIDE POTENTIAL SCREENING
i. Correctional or Transporting Officer reports inmate may be suicidal risk. Q Yes D No
2. Experienced a significant loss with}last six mon .1 al i {
D°¤°**b°* €,v~} {Lai $**1 at 2/ Hires I]No
3. Worried about major problems er than leg si tuatiop `
D°’“'b°: C®}\{l‘Lt"i MAJ léf MD ;¤,\`~mY\£._. E Yes D No `
I
4. Holds position of respect in community andfor alleged crime is shocking in nature. ij Yes Vt No
5. First involvement with legal system.
DCSCl'lbCZ D Yes HND
6. Appears to feel unusually embarrassed or ashamed. _ ‘ m Yes D No
7- Expresses feelings of helplessness or hopelessness. D Yes U No
8. Shows signs of depression: cryi g, emotional flatness.
Describe: ¢&M./7'I// ka/y—£/) €¢t»x.!JY`I` *3 , Hhs U No
9. Appears overl anxious, afraid, or angry.
I0. ls acting and/or talking in a strange manner. (cannot focus attention, hallucinating) D Yes D No
ll. Has made previous suicide attempt. '
Date of most Recent Attempt; Method: D yes NND
Number:
I 12. Expresses thoughts of killing self. E Yes HND
I3. Has a suicide plan.
Describe: U Yes D No
14. Expresses thoughts. of killing self. Sn Ir Jil/tf Ja? 6'C I. Bot, P Y\•S¤ El Yes H No
I5. Family member or significant other has attempted or committed suicide
Relationship: . E] yes %N0
· Date: Method:
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Case 1 :04-cv-00328-SLR Document 27-4 Fi_|ed O9/12/2005 Page 3 of 3
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DISPOSITION
(check all appropriate boxes) - -
lj Place on continuous suicide watch · \ 2
Flace on close suicide watch ( €.k/`{-4 i` I 5 h/I W `
Psychiatric medication order needed ` E A
FOR MENTAL HEALTH EVALUATION (check one box)
E mergency referral (l hour) l l
I · SAP referral (3 ryxs) W _ U _______ _____ pp )___ ____ _ _ Ap)____ ____ __i__r_L ________ )_ ___ _ ___LL is ,___ ...`..... l-.. . new
iii‘ i` " I 6u`iiHé`reféri·ali ` A (30 days) - A
I No referral A
FOR MENTAL HEALTH EVALUATION {check one box)
_ ._ Place in crisis/safe cell
Place in special housing
Place in general population
C°‘“"‘°““’ Tk/ly, c,m/cmp pr/69 yfqg, CM, · Rem {{q¤a¤»¤»·.»
Pc! 9c,c,¢Av"l( ger 5l‘\./\,{Q4\ "l~l¢» _ ’ 7L/G
QMU 2/ ’-· F L¤eerJi%‘-’ <’€"·/
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. Qcpci ‘r~ · ('}·éS€,r~x}·a.}l"\ q)·v——-......... ,
arnate Name: Inmate Number:
CVWMA P ,éY*y•,4_<§—{·’ fl! 2 ,
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Case 1:04-cv-00328-SLR

Document 27-4

Filed 09/12/2005

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Case 1:04-cv-00328-SLR

Document 27-4

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Case 1:04-cv-00328-SLR

Document 27-4

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