Click on the Inmate Mental Health Information Form, English Version

INMATE MENTAL HEALTH INFORMATION FORM
INMATE INFORMATION
FULL LEGAL NAME:
BIRTHDATE: ____________________________
ADDRESS BEFORE PRISON:
CDCR #:
HOUSING, IF KNOWN:
FAMILY CONTACT INFORMATION
THIS FORM IS BEING COMPLETED BY:
FAMILY MEMBER WHO CAN BE CONTACTED REGARDING THIS FORM:
RELATIONSHIP TO INMATE:
ADDRESS:
CITY:
DAYTIME PHONE:
STATE/ ZIP:
EVENING PHONE:
CELL:
MENTAL HEALTH INFORMATION
PSYCHIATRIST INFORMATION:
NAME:
ADDRESS:
PHONE:
APPROXIMATE DATES OF TREATMENT:
PSYCHOLOGIST/ COUNSELOR INFORMATION:
NAME:
ADDRESS:
PHONE:
APPROXIMATE DATES OF TREATMENT:
DESCRIBE THE INMATE’S MENTAL HEALTH HISTORY:
DIAGNOSIS:
MEDICATIONS:
Side effects or negative reactions to medications:
ARE YOU WORRIED THAT THE INMATE MIGHT HARM HIMSELF?
NO
YES
If yes, explain your concerns:
HAS YOUR FAMILY MEMBER ATTEMPTED SUICIDE IN THE PAST?
NO
YES
If yes, provide approximately date(s) and number of suicide attempts/threats:
What was going on that might have triggered suicidal thoughts or behavior?
MEDICAL INFORMATION
MEDICAL DOCTOR:
NAME:
ADDRESS:
PHONE:
APPROXIMATE DATES OF TREATMENT:
LIST MEDICAL CONCERNS:
MEDICATIONS:
NORTH KERN STATE PRISON CONTACT INFORMATION
PLEASE FAX OR MAIL THIS FORM TO:
DR. GREG HIROKAWA, CHIEF PSYCHOLOGIST
ADDRESS: NORTH KERN STATE PRISON/ P.O. BOX 567/ DELANO, CALIFORNIA 93216-0567
or
FAX: (661) 721-6262
NOTE: If you have any additional information you’d like to share, please attach a separate sheet. Thank you for your assistance!
This form was developed with the assistance of NAMI California
FORMULARIO DE INFORMACIÓN DE MEDICACIÓN DE PRESOS
INFORMACIÓN DEL PRESO
NOMBRE LEGAL COMPLETO DEL PRESO:_______________________________________________________________________________
CALLE: _______________________________________CIUDAD: ___________________ ESTADO: _____ CÓDIGO POSTAL: __________________
FECHA DE NACIMIENTO ______________________ N. DE REGISTRO:______________________________________________________________
UBICACIÓN EN LA CÁRCEL: TORRE: _________________ PISO: __________________________ N. DE PASILLO:___________________________
INFORMACIÓN DE CONTACTO DE LA FAMILIA
NOMBRE DE FAMILIAR DE CONTACTO: _____________________________________________ RELACIÓN:_______________________________
CALLE: ________________________________________CIUDAD: ___________________ ESTADO: _____ CÓDIGO POSTAL: _________________
N. DE TELÉFONO POR EL DÍA:__________________________________ N. DE TELÓFONO POR LA NOCHE: ______________________________
FIRMA DEL CONTACTO x___________________________________________________________________________________________________
INFORMACIÓN DE PSIQUIATRA O CENTRO DE TRATAMIENTO
PSIQUIATRA/ÚLTIMO CENTRO DE TRATAMIENTO: ____________________________________ULTIMO DÍA DE TRATAMIENTO: ______________
CALLE: ___________________________________________CIUDAD: ___________________ ESTADO: _____ CÓDIGO POSTAL: ______________
N. DE TELÉFONO: __________________________________________________ N. DE FAX:_____________________________________________
INFORMACIÓN MÉDICA
DIAGNÓSTICO:____________________________________________________________________________________________________________
MEDICINAS DE DIA: _______________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
MEDICINAS DE NOCHE: ____________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
EFECTOS NEGATIVOS ANTERIORES (por ejemplo, efectos secundarios, alergias, escasa eficacia): ________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
¿ES EL SUICIDIO UNA PREOCUPACIÓN? NO ______SÍ ______ EN CASO AFIRMATIVO, ¿POR QUÉ?____________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
OTRAS PREOCUPACIONES MÉDICAS:________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
NOMBRE DEL MÉDICO: _____________________________________________________ N. DE TELEFONO: _______________________________
CALLE: ______________________________________CIUDAD: ___________________ ESTADO: _____ CÓDIGO POSTAL: ___________________
NÚMERO DE FAX DEL SERVICIO DE SALUD MENTAL
NORTH KERN STATE PRISON CONTACT INFORMATION
DR. GREG HIROKAWA, CHIEF PSYCHOLOGIST
ADDRESS: NORTH KERN STATE PRISON/ P.O. BOX 567/ DELANO, CALIFORNIA 93216-0567
or
FAX: (661) 721-6262
ENVÍE UN FAX A AMBOS NÚMEROS CUANDO OTRAS CONDICIONES MÉDICAS SEAN RELATIVAS