Form TG-510-3 Mental Health Treatment Summary

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

Date of Birth__________ /__________ /___________ Medical Case Number:________________________________________________

(Mo/Day/Year)

Mental Health Treatment
Summary Form
OMB No.: 0420-0550
Expiration Date: 1/31/2014

mental health TREATMENT SUMMARY FORM
(Confidential)

The individual listed above has applied to serve as a Peace Corps Volunteer and has reported a history of a mental health
condition, mental health counseling, or use of medication for mental health. The mental health provider who has oversight and
management of the applicant’s treatment, or has access to the applicant’s mental health records, should complete this mental
health treatment summary. If you do not have access to the appropriate records, please indicate this on the form.
Note to the Mental Health Provider: Please be candid when answering the questions below. During Peace Corps service, a
Volunteer may be placed in a community that is very isolated and remote. It may have a history of violence or high crime, or
extreme poverty, or inequitable treatment. There may be limited access to Western-trained mental health professionals and little
support for existing or new mental health symptoms. Please answer all questions or the form will be considered incomplete
and returned to the applicant.

Privacy Act Notice
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility
for Peace Corps service and, if you are invited to serve as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps
service. Your disclosure of this information is voluntary; however, your failure to provide this information will result in the rejection of your application to become
a Peace Corps Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the routine uses listed in the Peace Corps’ System of Records.
Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties.
It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’
Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist or other medical personnel treating you or involved in your treatment
or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/
systemofrecords.pdf.

Burden Statement:
Public reporting burden for this collection of information is estimated to average 105 minutes per applicant and 60 minutes per mental health provider per response.
This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington, DC
20526 ATTN: PRA (0420 - 0550). Do not return the completed form to this address.

Peace Corps · Mental Health Treatment Summary Form

TG-510-3 (Initial approval 08/2012)

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Medical Case Number:

Mental Health Provider’s Name:__________________________________________________________________________________________________________________Date:_____________________
Professional degree:_____________________________________________________________________ License No.:_____________________________________________ State:________________
Address:_________________________________________________________________________________________________________________________________Tel:______________________________________________

1. Dates and Frequency of Therapy Sessions:
Date of First Session: _____________________________________________________________________ Frequency of Sessions:________________________________________________________
Date of Last Session: _____________________________________________________________________ Was this a Final Session? h Y h N
If yes, was termination satisfactory and/or mutual?__________________________________________________________________________________________________________________________
Please provide the following information based on your treatment and clinical assessment of this applicant. Please be as detailed
as possible. Continue on the reverse side of this page, if necessary.

2. Diagnoses [DSM IV Codes] (List all diagnoses)
Working Diagnoses

Date Given

Date Resolved

Current Diagnosis

Axis I:

(MM/YY)____________________ (MM/YY)____________________ Axis I:
h ongoing

Axis II:

Axis II:

Axis III:

Axis III:

Axis IV:

Axis IV:

Axis V:

Axis V:

3. Presenting Problem and Precipitating Factors:
4. Symptoms: Please be as specific and comprehensive as possible.
Symptom

Peace Corps · Mental Health Treatment Summary Form

Onset

Severity

TG-510-3 (Initial approval 08/2012)

Duration Date remitted

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Medical Case Number:

5. Course of Treatment:____________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
6. Psychotropic Medications: Current and Previous
Please have the prescribing professional complete this portion.
Medication and Dosage:_______________________________________________________________________________________________________________________________________________________
Start Date__________________________________________________________________________________ End Date:_____________________________________________________________________
Response to Medication:______________________________________________________________________________________________________________________________________________________
Recommended Monitoring Plan:__________________________________________________________________________________________________________________________________________
Medication and Dosage:_______________________________________________________________________________________________________________________________________________________
Start Date__________________________________________________________________________________ End Date:_____________________________________________________________________
Response to Medication:______________________________________________________________________________________________________________________________________________________
Recommended Monitoring Plan:__________________________________________________________________________________________________________________________________________
Medication and Dosage:_______________________________________________________________________________________________________________________________________________________
Start Date__________________________________________________________________________________ End Date:_____________________________________________________________________
Response to Medication:______________________________________________________________________________________________________________________________________________________
Recommended Monitoring Plan:__________________________________________________________________________________________________________________________________________
Signature and title if different from the person completing the rest of this form:______________________________________________________________
Name and title_____________________________________________________________________________________________Date___________________________________________________________

7. Mental Health History
Previous Counseling _
h N/A_
If yes, describe:

Dates if known

DSM Diagnosis if known

Psychiatric Hospitalizations_
h N/A_
If yes, describe:

Dates if known

Location

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Medical Case Number:

Suicide Attempt(s) dates)

Suicidal Gestures (dates)

Suicide Ideation (dates)

h N/A If yes, describe:

h N/A If yes, describe:

h N/A If yes, describe:

Risk of recurrence?

Risk of recurrence?

Risk of recurrence?

h None or unlikely

h None or unlikely

h None or unlikely

h Possible or likely (describe):

h Possible or likely (describe):

h Possible or likely (describe):

h I am unable to assess this

h I am unable to assess this

h I am unable to assess this

8. Level of Functioning
History

Interpersonal (describe):

Work (describe):

School (describe):

Current

Interpersonal (describe):

Work (describe):

School (describe):

9. Prognosis:_______________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
10. Risk of Exacerbation or Recurrence: Please consider issues of isolation, lack of structure, and lack of social
support in an austere environment overseas, __________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
11. Additional Comments:__________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________

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Medical Case Number:

12. Recommendations and Follow Up: What specific recommendations for mental health support do you have
regarding the management of this condition over the next three years? All recommendations will help determine
the best placement for the applicant as a Peace Corps Volunteer. Do you have any concerns that would prevent this
applicant from completing 27 months of service without disruption due to a mental health condition? NOTE: Peace Corps
service may be in areas that are isolated or have limited access to Western-trained providers and health care systems. Please
check one box below.
h I have no concerns. This applicant, with regard to mental health conditions, is healthy enough to complete 27 months of
uninterrupted Peace Corps service provided these recommendations can be accommodated.
h I am unsure that this applicant can, due to a mental health condition, complete 27 months of uninterrupted Peace Corps
service. I recommend a period of stabilization for this condition and an updated assessment at a future date. Describe and
include length of time for stabilization:________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

h I do not believe this applicant is or will be able to complete 27 months of Peace Corps service due to his/her mental health
condition.
I certify this information is, in my opinion, an accurate representation of the baseline status of this mental health condition
for the applicant listed above.
Mental Health Professional Signature/Title_______________________________________________________________________________________________________________________________________
Mental Health Professional Name (Print)__________________________________________________________________________________________________________________________________________
Date_____________________________________________________________________________________________________________________________________________________________________________________________________

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