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Home My WebLink Aboutab1424-formAB 1424 form rev. 10/2006 If available, this document should accompany the 5150 to the receiving facility. Alameda County Behavioral Health Care Services Historical Information Provided by Family Member or Other Interested 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. Mental health staff will place this form in the consumer’s mental health chart. Under California and Federal law, consumers have theright to view their chart 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 5328(b)}. This form was developed jointly by Alameda County Behavioral Health Care Services, Alameda County Family Coalition, family members, mental health consumers, mental health providers, patients’ rights advocates and the judicial system in order to provide a means for family members and other interested parties to communicate the client’s mental health history pursuant to AB 1424. Name of Consumer __________________________ Date of Birth ____________ Phone _________ Address __________________________________________________________________________ Primary Language______________________________ Religion____________________________ Medi-Cal: Yes No Medicare: Yes No Name of Private Medical Insurer ______________________________________________________ Yes No Please ask the consumer to sign an authorization permitting Alameda County mental health providers to communicate with me about his/her care. Yes No I wish to be contacted as soon as possible in case of emergency, transfer or discharge. Yes No The consumer has a Wellness Recovery Action Plan (WRAP) or Advance Directive. (If yes, and a copy is available, attach a copy to form.) Brief History of mental illness (age of onset, prior 5150’s, prior hospitalizations, history of violence, history of self harm, history of unstable living situations)(Attach additional pages, if necessary): Age illness began ______________ Prior 5150’s? No Yes If yes, how many _______________ Prior hospitalizations? No Yes If yes, how many _______________ Page 1 of 3 AB 1424 form rev. 10/2006 Does consumer have a conservator? No Yes Don’t know If yes, name _____________________________________________ phone: ___________________ Do you know consumer’s diagnosis? No Yes Don’t know Please explain: _____________________________________________________________________________ Do you know of any substance abuse problem? No Yes Don’t know Please explain: _____________________________________________________________________________ Current medications (Psychiatric and Medical) _________________________________________ Names: __________________________________________________________________________________ Medications consumer has responded well to: __________________________________________________________________________________ Medications that did not work for the consumer: __________________________________________________________________________________ Treating Psychiatrist and Case Manager Psychiatrist ______________________________________________ Phone ____________________ Case Manager ____________________________________________ Phone ___________________ Medical Significant Medical Conditions: _________________________________________________________ Allergies to Medications, Food, Chemicals, Other: __________________________________________ Primary Care Physician: ____________________________________ Phone: ___________________ Current Living Situation Family Independent Homeless Transitional Board & Care SIL Is this a stable situation for consumer? Information submitted by Name (print) ____________________________________ Relationship to consumer ______________ Address ___________________________________________________________________________ (city) (state) (zip) Phone __________________________ 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(d)}. Page 2 of 3 AB 1424 form rev. 10/2006 Alameda County Behavioral Health Care Services Historical Information Provided by Family Member or Other Interested Party Name of Consumer ________________________ Date of Birth __________ Phone _____________ History of Consumer’s Decompensation Please check off symptoms or behaviors that consumer has had in past when decompensating and indicate which ones you are observing with the consumer now. Symptom or Behavior Past Now Symptom or Behavior Past Now suicide gesture/attempts weepiness suicidal statements being too quiet thinking about suicide expressing feelings of worthlessness cutting on self afraid to leave the house harming self giving away belongings sleeping too much increased irritability and/or negativity not sleeping laughing inappropriately not eating stopping medication suspicious (paranoia) repetitive behaviors fire setting forgetfulness aggressive behavior (fighting) not paying bills threats taking more medication than prescribed irrational thought patterns (not making sense) failing to go to doctor’s appointments destruction of property spending too much money sexual harassing/preoccupation poor hygiene hearing voices overeating lack of motivation impulsive behavior anxious and fearful not answering phone/turning off phone machine avoiding others or isolating talking to self talking too much or too fast substance abuse argumentative homelessness or running away Please describe recent history and behaviors that indicate dangerousness to self, dangerousness to others and/or make the consumer unable to care for him/herself. 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