Form PC-262-8 Eating Disorder Treatment Summary Form

Applicant Name

(Last, First, Middle Initial)

Date of Birth___________/_________ /___________

(Mo/Day/Year)

Eating Disorder Treatment Summary Form

(Confidential)

The individual listed above has applied to serve as a Peace Corps Volunteer and has reported a history of an eating disorder or disordered eating patterns. 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 form. If you do not have access to 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, with the potential for a history of high crime, history of violence, current extreme poverty, and/or inequitable treatment of members of the population. There may also be limited access to Western-trained mental health professionals and little support for existing or new mental health symptoms. Please take these factors into consideration when answering the questions below. This form will also be considered “incomplete” and returned to the applicant if all questions are not answered.

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 service 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 or failure to disclose relevant information may 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 U.S.C. 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, licensed clinical social worker 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 20^th Street, NW, Washington, DC, 20526 ATTN: PRA (0420-0550). Do not return the complete from to this address.

Treatment Summary Form PC‐262-8 (Previous editions are obsolete) Page 1 of 6

Mental Health Provider’s Name and Degree (Print): _________________________________________________________

Date: ______________________ License No.: ________________________________ State: ______________________

Address: ____________________________________________________________ Phone: _______________________

Do you possess specialty training in care or assessment of eating disorders?  Yes  No

Dates & Frequency of Therapy Sessions

Date of First Session: ______________________ Frequency of Sessions: ______________________________________

Date of Most Recent Session: ______________________ Was this a Final Session:  Yes  No

If marked “Yes,” was termination satisfactory and/or mutual? _______________________________________________

Course of Treatment

Please identify the modality, treatment goals, applicant’s reaction to treatment, and any other relevant clinical information.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Please provide the following information based on your treatment and/or clinical assessment of this applicant. Please be as detailed as possible.

A. Past & Current Clinical Disorders (Formerly Axes I, II, and III in DSM-IV-TR)

Please indicate date given and date remitted, if applicable. Please also indicate if no current diagnosis is present or if diagnosis is ongoing.

Mental Disorders:

Diagnosis	Date Given	Date Remitted	Ongoing
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No

General Medical Disorders:

Diagnosis	Date Given	Date Remitted	Ongoing
			 Yes  No
			 Yes  No
			 Yes  No
			 Yes  No

Peace Corps – Eating Disorder Treatment Summary Form PC‐262-8 (Previous editions are obsolete) Page 2 of 6

B. Past & Current Physical & Mental Health Symptoms

Please be as specific and comprehensive as possible, to include residual symptoms, weight control behavior, and physical concerns that were consequences of behaviors.

Symptom	Onset	Severity	Duration	Date Remitted

Documentation of weight over the past three years: _________________________________________________________________________________________________

_________________________________________________________________________________________________

C. Psychotropic Medications (Current & Previous)

*** If possible, please have the prescribing clinician complete this section. ***

Medication and Dosage	Start Date	End Date	Response to Medication	Recommended Monitoring Plan

Signature: _________________________________________________________ Date: _________________________

Name & Title (Print): ______________________________________________________________________________

Peace Corps – Eating Disorder Treatment Summary Form PC‐262-8 (Previous editions are obsolete) Page 3 of 6

D. Past & Current Mental Health/Disordered Eating Hospitalizations & Treatment

Past Treatment?  Yes  No Date(s): _________________ *From intake to discharge If “Yes,” please describe context/reasons. _______________________________ _______________________________ _______________________________ _______________________________ _______________________________

Current Treatment?  Yes  No Date: ___________________ *Intake If “Yes,” please describe context/reasons. _______________________________ _______________________________ _______________________________ _______________________________ _______________________________

Hospitalizations?  Yes  No Date(s): _________________ *From intake to discharge If “Yes,” please describe context/reasons. _______________________________ _______________________________ _______________________________ _______________________________ _______________________________

E. Past & Current Risk Assessment/Information

Suicide Attempt?  Yes  No Date(s): ______________ If “Yes,” please describe context(s) and reason(s). _____________________ _____________________ _____________________ Rick of Recurrence (Check One):  None/Unlikely  Possible/Likely Describe: _____________________ _____________________ _____________________  I am unable to assess this

Suicide Gesture?  Yes  No Date(s): ______________ If “Yes,” please describe context(s) and reason(s). _____________________ _____________________ _____________________ Rick of Recurrence (Check One):  None/Unlikely  Possible/Likely Describe: _____________________ _____________________ _____________________  I am unable to assess this

Suicide Ideation?  Yes  No Date(s): ______________ If “Yes,” please describe context(s) and reason(s). _____________________ _____________________ _____________________ Rick of Recurrence (Check One):  None/Unlikely  Possible/Likely Describe: _____________________ _____________________ _____________________  I am unable to assess this

Self-Injurious Behaviors?  Yes  No Date(s): ______________ If “Yes,” please describe context(s) and reason(s). _____________________ _____________________ _____________________ Rick of Recurrence (Check One):  None/Unlikely  Possible/Likely Describe: _____________________ _____________________ _____________________  I am unable to assess this

Peace Corps – Eating Disorder Treatment Summary Form PC‐262-8 (Previous editions are obsolete) Page 4 of 6

F. Clinical Assessment

Psychological tests/measures administered:

(Please attach pertinent reports or summaries, if any)

1. ____________________________________________________________________________________________

2. ____________________________________________________________________________________________

To the best of your ability, describe the applicant’s ego strength, emotional stability, and flexibility:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

To the best of your ability, describe the applicant’s coping strategies: ________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

To the best of your ability, describe the applicant’s overall functioning (interpersonal and work) and prognosis based on your clinical observations:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

What is the applicant’s plan for maintaining healthy weight, diet, and exercise while serving in the Peace Corps?

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

To the best of your ability, rate and describe the applicant’s risk of relapse in a stressful overseas environment (characterized by isolation, lack of structure, limited social supports, restrictive food environments, and restrictive exercise environments):

 High/Likely  Possible  Low/Unlikely

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Peace Corps – Eating Disorder Treatment Summary Form PC‐262-8 (Previous editions are obsolete) Page 5 of 6

G. Recommendations & Follow Up

What specific recommendations for eating disorder support do you have regarding the management of this applicant’s condition over the next three years? All recommendations will help determine the best placement for the Peace Corps applicant. ________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Any other comments or concerns related to the information provided on this form or regarding this applicant?

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

I certify this information is, in my opinion, an accurate representation of the baseline status of this eating disorder condition for the applicant listed above.

Mental Health Provider’s Signature: _____________________________________________________________________

Date: ____________________________

Peace Corps – Eating Disorder Treatment Summary Form PC‐262-8 (Previous editions are obsolete) Page 6 of 6