Get Behavioral Health Treatment Record Review Sample Treatment Forms

The Behavioral Health Treatment Record Review Sample Treatment Forms are essential tools for documenting patient treatment and care in behavioral health settings. This guide provides clear instructions on how to fill out these forms effectively in an online format.

Follow the steps to successfully complete the treatment forms online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling out the demographic information section, which includes the date, name, address, phone numbers, date of birth, social security number, guardianship status, marital status, and family member details.
3. Next, input the emergency contact information. Provide the name, phone numbers, and relationship of the emergency contact.
4. Continue with the presenting problem section by describing the issues experienced, including onset, duration, and intensity.
5. Document any precipitating events that indicate the reason for seeking treatment.
6. List target symptoms along with their frequency, duration, and degree of impairment in the relevant fields.
7. In the mental status section, circle the appropriate items related to orientation, affect, mood, thought content, and other necessary observations regarding the patient.
8. Conduct a thorough risk assessment for suicidal and homicidal ideation, checking the relevant boxes and providing comments as necessary.
9. Fill out the medical and behavioral health history, including allergies, current medications, psychiatric history, and any past hospitalizations.
10. Provide psychosocial information by outlining support systems, school or work life, and any legal history.
11. If applicable, fill out the substance abuse history section for patients aged 12 and over, providing details about substance use.
12. If the patient is a child or adolescent, complete the developmental history and identify any risk factors.
13. Finish by entering the diagnostic impression across different axes and ensuring the patient signature and provider signature sections are filled in.
14. At the final step, users can save changes, download, print, or share the completed form.

Start filling out the Behavioral Health Treatment Record Review Sample Treatment Forms online today!