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Assesments & Psychiatric

A psychiatric evaluation is a comprehensive evaluation that investigates the recipient’s clinical status.

The purpose of a psychiatric evaluation is to establish a therapeutic doctor–patient relationship, gather accurate data in order to formulate a diagnosis, and initiate an effective treatment plan.

 

Evaluation Components

A psychiatric evaluation must provide information on the following components:

  • Presenting problems

  • History of the presenting illness or problem

  • Psychiatric history

  • Physical history

  • Trauma history

  • Medication history

  • Alcohol and other drug use history

  • Relevant personal and family medical history

  • Personal strengths

  • Mental health status examination

  • Summary of findings

  • Diagnostic formulation

  • Treatment recommendations or plan

 

 

Assessment and Evaluation Process

Right Path Behavioral Health Services will provide assessments and bio-psychosocial evaluations for clients applying for behavioral health services. Each behavioral health therapy client will receive a complete and thorough assessment. The assessment of each client shall include clinical consideration of the client’s general physical, medical, developmental, family, social, psychiatric, and psychological history and current condition. The diagnostic statement shall include the diagnosis based on the codes in Diagnostic and Statistical Manual of Mental Disorders –IV or 5 and refer to the pertinent assessment data. The diagnosis shall be by or under the supervision of and signed by a Physician, Psychiatrist, LPHA, Master’s level CAP, Master’s  level practitioner, CAP, or Bachelor’s level practitioner.

 

Assessment Services

All assessments services must be billed with the correct procedure code and modifier found in the appendices.

Assessment services include the following:

  • Psychiatric evaluation

  • Brief behavioral health status examination

  • Psychiatric review of records

  • In-depth assessment

  • Bio-psychosocial evaluation

  • Limited functional assessment