Form Approved
OMB No. 0920-0006
Exp. Date: xx/xx/xxxx
FOLLOW UP OF IMMIGRANTS OR REFUGEES WITH CLASS A PHYSICAL OR MENTAL CONDITION
This will satisfy the agreement of health care provider to document that he/she supplied counseling and any treatment or observation necessary for the proper management of the alien’s mental disorder
NAME OF PATIENT: _________________________________Date of Birth __________
Mo/ da / year
Sex Male Female Country of Birth_______________
Race___________________ Ethnicity: _______________________
Date of Patient’s first visit______________Date of most recent visit______________
Mo/da/year Mo/da/year
Nature of Visit: Substance abuse or addiction disorder yes no
Other mental disorder yes no
______________________________________________________________________________
Current Diagnoses:
Axis I________________________________________________________________________
Axis II________________________________________________________________________
Axis III_______________________________________________________________________
Axis IV_______________________________________________________________________
Axis V________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0006).
Current Status:
Is the patient a danger to self? yes no
to others? yes no
Does patient require treatment? yes no
If follow up treatment is recommended, will patient remain under your care? yes no
If no, are you referring to another specialist? yes no
If yes, give name and address of specialist____________________________________________
Has the patient followed treatment as prescribed, including any medications, keeping appointments, getting necessary laboratory work, psychoeducation or psychotherapy ?
yes no
Treatment recommended Yes No . If yes, what is the current treatment plan__________________________________________________________________________ ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Printed or typed name of current physician___________________________________________
Mailing address______________________________City________________State______
Zip_____________ Phone ( )____________Fax ( )________________
Signature___________________________________________Date_______________________
CDC 4.422-1a
| File Type | application/msword |
| Author | ije7 |
| Last Modified By | ziy6 |
| File Modified | 2011-07-06 |
| File Created | 2011-07-06 |