ࡱ> _ bjbj Dbbbbd%$[[[#######$&(#[[[[[##}}}[ #}[#}}V!@!WXX5XeRP! ##0%$\!xS)`S)!S)![[}[[[[[##f[[[%$[[[[S)[[[[[[[[[b :  PASRR CATEGORICAL DETERMINATION FORM NEW JERSEY DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES PLEASE PRINT CLIENTS NAME: _____________________________________ ______________________________________ _______________ Last First M.I. SECTION 1 CLIENT LOCATION AND IDENTIFYING INFORMATION (to be completed by person referring client for evaluation): SOCIAL SECURITY NUMBER: __________ _______ _________ DATE OF BIRTH: _________ / _______ /___________ INSURANCE: ______ MEDICAID ______ MEDICARE _______ PRIVATE INSURANCE ______ OTHER ________________________ COUNTY WHERE CLIENT IS TODAY: _____________________________________________________________________________________ REFERRING FACILITY INFO: ____Psych. Hospital (involuntary unit) ____Psych. Hospital (voluntary unit) ____General Hospital _____Home _____Nursing Fac. /Assist. Living ____ Other Residential Setting (RHCF, Group Home, Etc.) Describe: _______________ Name/Complete Address of facility ______________________________________________________________________________ Referring or Contact Person___________________________________ Relationship to client _____________________________ Email: _______________________________ PHONE: ________________________ FAX: _____________________________ SECTION 2 CATEGORICAL DETERMINATION (Type of categorical determination requested): ______ TERMINIAL ILLNESS (Documented terminal illness) ______ SEVERE PHYSICIAL ILLNESS (Severe physical illness such as coma, ventilator dependent, progressed ALS, Huntingtons, COPD, etc.) ______ RESPITE CARE (Placement in NF up to 30 days to provide respite to home caregivers) ______ PROTECTIVE SERVICES (Placement in NF not to exceed 7 days in order to provide protective services in emergency situations) SECTION 3 CLIENTS DIAGNOSES: (List all medical and psychiatric diagnoses): _________________________________________________ ________________________________________________________________________________________________________________________ SECTION 4 PSYCHIATRIC EVALUATION (to be completed by Independent Psychiatrist or Psychiatric APN) HAVING PERSONALLY ASSESSED THIS CLIENT AND REVIEWEDTHE AVAILABLE CLINICAL RECORDS IT IS MY PROFESSIONAL OPINION THAT THE CLIENT: _____ NO _____ YES HAS RISK TO SELF OR To OTHERS: SYMPTOMS ARE STABLE _____ NO _____ YES HAS A MAJOR MENTAL ILLNESS _____ NO _____ YES HAS MENTAL HEALTH TREATMENT NEEDS THAT CAN BE MET IN A NURSING FACILITY _____ NO _____ YES REQUIRES SPECIALIZED SERVICES (e.g., 24-hour inpatient psych. treatment) (NOTE: IF MENTAL HEALTH NEEDS CAN BE MET IN A NURSING FACILITY, SPECIALIZED SERVICES CANNOT BE REQUIRED) I certify that the above is true and that the categorical determination is supported by the medical, psychiatric and the other documentation provided (all supporting documentation must be faxed along with this form). Print Name and Title of Examiner: _______________________________________________________________________________ Signature of Examiner:________________________________________________________________________________________ Telephone # _____________________________________ Exam Date ________________________________________ DO NOT WRITE BELOW THIS LINE____________________________________________________ SECTION 5 DMHAS DETERMINATION: (To be completed by Psychiatrist / APN at NJ DMHAS) THIS CLIENT HAS INDICATORS THAT MEET CRITERIA FOR THE FOLLOWING CATEGORICAL DETERMINATION: _____ TERMINAL ILLNESS _____ SEVERE PHYSICAL ILLNESS _____ RESPITE CARE _____ PROTECTIVE SERVICES _____ NO _____ YES HAS MENTAL HEALTH TREATMENT NEEDS THAT CAN BE MET IN A NURSING FACILITY _____ NO _____ YES THIS CLIENT NEEDS SPECIALIZED SERVICES (24-HOUR INPATIENT PSYCHIATRIC TREATMENT) Signature: _________________________________________ Date: _____________________ FAX THIS EVALUATION TO THE DMHAS PASRR 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Hospital (involuntary unit) ____Psych. Hospital (   ;2  0 voluntary unit) ____General H   2 0 ospital  2 0  #  2 0     2 00    2 30    2 ,00 ___ 2 ,B0 __ 2 ,N0 Home    2 ,n0   2 ,q0 ___ 2 ,0 __ 2 , 0 Nursing Fac   2 ,0 .  2 ,0   2 ,0 /Assist   2 ,0 .  2 ,0   2 ,0 Living 2 ,0    2 ,0   2 , 0 ___  2 ,20 _  2 ,80   s2 ,;E0 Other Residential Setting (RHCF, Group Home, Etc.) Describe: ________       2 ,0 _______  2 ,0    2 :00    2 :<0    2 G0 0 Name/Comple    ,2 Gu0 te Address of facility   2 G0   h2 G>0 ______________________________________________________________ 2 GR0 __  2 G^0 ______________  2 G0     2 U00    q2 c0D0 Referring or Contact Person___________________________________   2 c0    2 c0   ,2 c0 Relationship to client  2 c0   52 c 0 ____________________________  2 c0 _  2 c0   --- 2 q00   2 q60    2 qH0     2 00   2 30 Email  2 N0 : ____  2 n0 _ 2 t0 __ 2 0 ______ &2 0 __________________  2 0   72 0 PHONE: ______________________  2 0 __ 2 0   2 0 FAX: _  2 0 ____ 2 0 _______ 2 D0 ___ 2 V0 ___ 2 h 0 __________  2 0 _ 2  0    2 0    2 0   ---  2 00   --- 2 00 SECTION    2 g0    2 i0 2 2 o0   2 { 0 CATEGORICAL    "2 0 DETERMINATION (    --- M2 I,0 Type of categorical determination requested)   2 !0 :---  2 $0  - @ !?0- ---  2 00    2 00 ______  &2 W0 TERMINIAL ILLNESS      72 0 (Documented terminal illness)    "2 `0   2  0    2 0    2 00 ______  12 W0 SEVERE PHYSICIAL ILLNESS      2 0 (  2 0 Severe physica P2 J.0 l illness such as coma, ventilator dependent,   I2 )0 progressed ALS, Huntingtons, COPD, etc.)      2 0    2 00 ______  2 W 0 RESPITE CARE   12 0 (Placement in NF up to 30    2 +0   L2 .+0 days to provide respite to home caregivers)   2 0   )2 0   "2 =0    2 j0    2 00 ______  2 W0 PROTE   2 ~0 C 2 0 TI  2 0 V 2  0 E SERVICES  2 f0 (Placement in NF not to exceed 7 days in order to provide protective services in emergency situations)     2 0     2 00   --- 2 0 0 SECTION 3   2 o0   )2 x0 CLIENTS DIAGNOSES:    --- O2 -0 (List all medical and psychiatric diagnoses): ---  2 0   (2 0 ___________________ 2 K 0 ____________ &2 0 __________________  2 0  - @ !?0-- @ !*- ---  2 00    2 0x0 ________________________________________________________________________________________________________________________  2 0  - @ !0- ---  2 $00   --- 2 200 SECTION     2 2i0 4  2 2o0   2 2r0   ,2 2x0 PSYCHIATRIC EVALUATION   ---  2 20   2 2#0 (to be  2 2?0   2 2B 0 completed by   2 20    2 20 I J2 2*0 ndependent Psychiatrist or Psychiatric APN   2 2^0 )   2 2d0   2 2g0 HAVING   2 20 PERSON  2 20 ALLY - @ !?30- --- 12 @00 ASSESSED THIS CLIENT AND      2 @0 REVIEWED   2 @0 THE   22 @/0 AVAILABLE CLINICAL RECORDS         2 @0    2 @0   F2 @'0 IT IS MY PROFESSIONAL OPINION THAT THE           2 N00 CLIENT:   2 N^0     2 [00    2 [30    2 i00 ____  2 iH0 _  2 iN0   2 iQ0 NO  2 ie0   2 ik 0 _____ YES  2 i0   2 i0 HAS  #2 i0 RISK TO SELF OR     2 i40 To  42 iD0 OTHERS: SYMPTOMS ARE STABLE        2 i0     2 w00   2 w30 _____ NO   2 wf0    2 wh0    2 wk0   2 wn 0 _____ YES  2 w0   42 w0 HAS A MAJOR MENTAL ILLNESS          2 wl0     2 00   2 30 _____  2 T0 NO  2 f0    2 k0   2 n 0 _____ YES  2 0   \2 60 HAS MENTAL HEALTH TREATMENT NEEDS THAT CAN BE MET IN A                   2 .0    2 10 N  #2 :0 URSING FACILITY     2 0     2 00   2 3 0 _____ NO   2 h0   2 n 0 _____ YES  2 0   2 0 REQUIRES   2 0   .2 0 SPECIALIZED SERVICES     2 0 ( 2 0 e.g.,  2 0 24  2 0 - :2 0 hour inpatient psych. treatment   2 E0 )  2 I0    2 K0     2 00    2 30 ( 2 70 NOTE:  /2 ]0 IF MENTAL HEALTH NEEDS C         :2 0 AN BE MET IN A NURSING FACILITY        2 0 ,   2 0  +2 0 SPECIALIZED SERVICES    2 h0   &2 n0 CANNOT BE REQUIRED     2 0 )  2 0    2 0   @Times New Roman---@Times New Roman--- @Times New Roman-------- 2 0 0 I certify  2 Z 0 that the  &2 0 above is true and  @2 #0 that the categorical determination   )2 0 is supported by the  2 0 medical   2  0 ,---  2 0  --- 2  0 psychiatric   2 J0    2 00 and  2 F0 the  2 X0 other  2 q0    2 u0 documentation   2 0 provided  2 0    2 0 ( 72 0 all supporting documentation   2 0 must be   2 0   /2 0 faxed along with this fo 2 '0 rm   2 40 )  2 80 .  2 ;0   ---  2 00    ;2 0 0 Print Name and Title of Examiner     2 0 :  2 0    2 0 ______________ 2 . 0 ___________ 2 p 0 ___________ 2  0 _________ #2 0 ________________ 2 H0 ______ 2 l0 ____ 2 0 ______ 2 0 __   2 0     2 00    +2 00 Signature of Examiner  72 0 :____________________________  2 E0 _ #2 K0 ________________ 2  0 __________ +2 0 _____________________ 2 e0 ______ 2 0 _____  2 0 _  2 0     2 00    ,2 00 Telephone # __________ "2 0 _______________  2 0 _ 2  0 ______ 2 /0 __ 2 ;0 ___  %2 P0   2  0 Exam Date _   2 0 ________ :2 0 _______________________________  2 0     2 *00   @Times New Roman- - -   0  2 91   2 80   2 94   2 83   2 97   2 86   2 9:   2 89   2 9=   2 8<   2 9@   2 8? 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