Full Text
1 of 4 Updated 6-26-2017 Health System AB 1424 Form: Historical Information Provided by Family Member or Other Concerned Party California Assembly Bill 1424 (2001), now a law, requires all individuals making decisions about involuntary treatment to consider information supplied by family members and other interested parties. Behavioral Health Staff will place this form in the client’s mental health chart. Under California and Federal law, clients have the right to view their charts. The Family Member completing this form has the right to withdraw consent to release information given by them and have the information regarded as confidential (Welfare & Institutions Code Section 5328(b)). This form was developed originally by San Mateo County BHRS (and adapted by Alpine County Behavioral Health Services), behavioral health clients and health providers in order to provide a means for family members and other interested parties to communicate the client’s behavioral health history to hospitals/outpatient staff or 911 responders. Today’s Date: Name of Person Submitting This Information: Relationship to Client: Yes No I wish for the client to sign an authorization permitting Alpine County Behavioral Health Services to communicate with me about his/her care. Yes No I wish to be contacted as soon as possible in case of emergency, transfer and/or discharge. Yes No Client has a Wellness Recovery Action Plan (WRAP) or Advance Directive. (If yes and available, please attach a copy to this form.) Brief history of mental illness (age of onset, prior 5150s, prior hospitalizations, history of unstable living conditions, if applicable – attach additional pages if necessary): Age or illness began: Prior 5150’s? Yes No If yes, Prior Hospitalizations? Yes No If yes, when/where? Does the client have a conservator? Yes No Don’t Know If yes, Name: Phone: www.alpinecountyca.gov Client Information Name: Date of Birth: Phone: Address: Primary Language: Religion: Medi-Cal: Yes No Medicare: Yes No Name of Private Medical Insurer: ---PAGE BREAK--- 2 of 4 Updated 6-26-2017 Name of Client: Do you know the client’s diagnosis? Yes No Don’t Know Please explain: Do you know of any substance abuse problems? Yes No Don’t Know Please explain: Are there any family traditions, spiritual beliefs, or cultural concerns that are important to know about? Is there anything about the client’s sexual orientation/gender identity to be aware of? Please describe any triggers (events or persons) that can precipitate a crisis: Current Medications and Medical): Names/Doses: Treatments that have helped: Treatments that have not helped: Phone: Case Manager/Therapist: Phone: Medical Information: Significant Medical Conditions: Allergies (all): Primary Care Physician: Phone: Current Living Situation: Family Independent Homeless Transitional Board & Care Supported Housing Other Is this a stable situation for the client? ---PAGE BREAK--- 3 of 4 Updated 6-26-2017 Name of Client: Please check or behaviors that the client has had in the past when decompressing (becoming unstable) and indicate which ones you are observing now: or Behavior Past Now Homelessness or Running Away Avoiding Others or Isolation Not Answering Phone/Turning Off Voicemail Afraid to Leave Home Being Too Quiet Crying/Weepiness Lack of Motivation Expressing Feelings of Worthlessness Anxious and/or Fearful Talking Too Much, Too Fast, Too Loud Spending Too Much Money Impulsive Behavior Laughing Inappropriately Argumentative Sleeping Too Much Not Sleeping Not Eating Over-Eating Repetitive Behaviors Forgetfulness Please describe recent history and behaviors that indicate dangerousness to self, dangerousness to others and/or make the client unable to care for him/her self: Information Submitted By: Name (print): Phone: Address: Signature: Date: A person “shall be liable in a civil action for intentionally giving any statement that he or she knows to be false”. (Welfare & Institutions Code Section 515.05 or Behavior Past Now Suicidal Gesture/Attempts Suicide Statements Thinking About Suicide Giving Away Belongings Stopping Medication Substance Use/Abuse Taking More Medication than Prescribed Irrational thought Patterns Hearing Voices Poor Hygiene Cutting Self Harming Self Failing to Go to Doctor’s Appointments Sexual Harassing/Preoccupation Fire Setting Aggressive Behavior (Fighting) Destruction of Property Increased Irritability and/or Negativity Making Threats of Violence Not Paying Bills ---PAGE BREAK--- 4 of 4 Updated 6-26-2017 California AB 1424 On October 4, 2001 Assembly Bill 1424 (Thomson-Yolo D) was signed by the Governor and chaptered into law. The law became effective January 1, 2002. AB 1424 modifies the LPS Act (Lanterman, Petris, Short Act), which governs involuntary treatment for people with mental illness in California. The legislative intent is as follows: Many families of person with serious mental illness find the Behavioral Healthcare System difficult to access and not supportive of family information regarding history and Person with mental illness are best served in a system of care that supports and acknowledges the role of the family, including parents, children, spouses, significant others, and consumer-identified natural resource systems. It is the intent of the Legislature that behavioral health procedures be clarified to ensure that families are a part of the system response, subject to the rules of evidence an court procedures. More specifically, AB 1424 requires: • The historical course of the person’s mental illness be considered when it has a direct bearing on the determination of whether the person is a danger to self/others or gravely disabled; • Relevant evidence in available medical records or presented by family members, treatment providers, or anyone designated by the client be considered by the court in determining the historical course; • Facilities make every reasonable effort to make information provided by the family available to the court; and • The person (a law enforcement officer or designated mental health professional) authorized to place a person in emergency custody (a “5150”) consider information provided by the family or a treating professional regarding historical course when deciding whether there is probably cause for hospitalization. Communicating with Behavioral Health Providers about Adult Mental Health Clients Alpine County Behavioral Health Services recognizes the key role families play in the recovery of clients receiving our services. We encourage providers at every level of care to seek authorization from the client so that family members will be involved and informed in their care. We have a special authorization form expressly designed to facilitate communication between treatment teams and family members. We hope the summary below clarifies how laws concerning confidentiality affect communications between families and mental health providers concerning mental health clients aged 18 or older. Outpatient Services • California and Federal law require that behavioral health providers obtain authorization from the client before they are able to communicate with family members, even to reveal that person is a client. Behavioral health providers can, however, listen to and receive information from family members. Hospital Services • California law requires that hospitals inform families that a client has been admitted, transferred, or discharged unless that client requests that the family not be notified. o Hospitals are required to notify clients they have the right not to provide this information. • California and Federal law require that hospital staff obtain an authorization to disclose anything else to family members. What the Family Can Do: • Although behavioral health providers are constrained in their ability to communicate with families, family members may communicate with treatment teams with or without an authorization from the client. o Family members and other interested parties can use this form to provide information about the client to hospital or outpatient staff. Staff will place this information in the client’s behavioral health chart. Under California and Federal law, clients have the right to view their chart. The family member completing the AB 1424 form has the right to withdraw consent to release information given by them and have the information regarded as confidential. o Although the treatment team may not be able to disclose information to the family member, they are free to consider any information the family provides.