Initial psychiatric screening.
Baker Act | Marchman Act | Ex-Parte | Voluntary
Initiated by: Judge | Police | Provider | Other
If police, specify department:
Mental Status Exam
Appearance | Appropriate | Disheviled | Other
Mood | Appropriate | Angry | Sad | Manic | Other
Affect | Appropriate | Flat | Restricted Other
Motor Behavior | No Abnormalities Catatonic
Speech | Unremarkable Pressured Hesitant
Thought Process | Coherent Incoherent
Judgement/Insight | Adequate Fair Poor
AVH/Delusions | Present Not Present Other
Suicidal Threat/Attempt | Homicidal Threat/Attempt | Self-Inflicted Injury | Traumatic Event | Legal Court Order | Physician Order | Impulsive/Dangerous BehaviorPsychotic Features | Cognitive
Psychiatric Treatment/Hospitalization | ECT | Substance Abuse Treatment | No Previous Treatment
Current Living Arrangement
SNF or ALF?
Active Abuse | Past History | No History
Active | Early Remission | Sustained Remission
History of Abuse/Trauma
Physical | Sexual | Emotional
Difficulty Falling Asleep
Difficulty Staying Asleep
Ear Plugs/Face Mask
History of Eating Disorder Yes | No
Weight Change in Last 3 Months Yes | No
Weight Change in Last 6 Months Yes | No
Intentional Weight Change Yes | No
Appetite Increased Yes | No
Appetite Decreased Yes | No
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