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CARE MANAGER CONTACT LOG - DEPRESSION &. PTSD

M F DOB: ID#:_ _ _ _ _ _ _ _ _ _ _ _ ~ " . _ ; _ . . , - - - - -Date ofIndex om=.c-ce"""'v:c:isl:-:C-t;-_-"""'/,-_---:---PatientName:Addres:;:Practice: Clinician: - , - - - - : = - _ : - : - ; - _ ~ - - - - - _ = , _ _ _ _ - - - .PrimaryPhone# L - l _ _ - (Type_ _ -.,-) A1lematePhone# L - l _ _ - (Type _Call Interval (1,.fit..,I/Ol..1.ItI): 1 Wk 4 Wks 8 Wks 12Wks 16 Wks (----lWksCall Type: Initial PRN Routine Phase: Acld;e Continuation MaintenanceCompletedCuD-Date: __ I__ / __ Starttime __ :__ Endtime __ :__ TotalTime: _ _ minutes

"Uii .'iiUjj."i,.....)Attempt Date Time Home Work Other (sueciM NoAns. Left MCS882e1HOW? Busy Not Avail.

#1#2#3

it t '" .... , . " 1. ,W(l)Cimflmr a i b ! d , 4 J t e t n P t s R ~ c h d- A e t i t 1 " T l l k t t l l ~ " ) (CW#1Mt 1 1 J J 1 l } ~

Primarycare Cliaichm eonbleted by pholN 14ft,r Letict to patient Patientdi$enrol1edtdale: )OIhcr

PrescriptiQllSfilled, but not begunPrescriptiollSstoppl by:

(Cbed WIt) Patient FCCOther( )

AddiU(lIllllpre!iCtJptiontIrillc but not begunPl'eIlClipti(lllSbegun and/orcmtinued \I$.dirccted

D.wUf.RSBNCOUMUlD B U _ )tJncM.atntYabOUtmedicationet'feeuven6SS

Few oraddietiQllD i ~

withdiee,l1osisMedicationcosts A!tIl:livalenceabolltdiagJtosisSt ipe UnsupporliVefl1tlilylfriendsSide cl'feots(CJiick all ditir 'fP.\IJ

or Sc49tiO/l J\gillIlitniAmiiety Ory.M(IIlt,hSleeppl:oblems Oecrease4 SQI:drive

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Sleeppl:oblems Oecrease4 SQI:drive

Disagreeswith diagnosis Ambivalenceabout diagnosisStigma Unsupportive family/mends

Counseling c osts No accessible counselorMissed/forgot a ppt Ins.lmanaged care problemsNo transportation Excessive waitfor appt.Uncertainty about counseling effectivenessOtherS i f :

Symptoms Score

gJl!!!pJ!l!lwlWJi:A!!!M!1lI!t!l.i l 0 t H ! t ? ! L ~ i " 8 I ; ' n . 1 L l ~ : ~ Q 2 ' -# l I I t " , OOcpme: ~ l h o u i b t s0I'Ilyim' ~ O I \~ q u i r t d~ thoJ.!&bls CQlffmt'fltnM t1l:tionSJaktn fJJCJudtnadinJIIllI COIlltW:

Symptoms

Cqmplm Suicii,JmUttW/l,lfQutll/M "lP# IC9I' II t Ap r 3.M . _ I m t CIutgqme: ~ t f t o l l 8 h UCIiIYfnoalltlOlt required

, 1 l , 1 i ~tbouglllr>.C_*'I11.IIId alrioru m'-iTlCllirJillgqi!mjun1,'!?!!JIl#(

"" ... ii,8&...." i'',8&B';J.' ......&