Mental Health Notes Summary (Non-Psychotherapy Note) Instructions · A mental health professional may use this form to submit mental health notes. · BWC/managed care organizations (MCOs) will use this mental health notes summary as part of the management of the medical part of the claim. · Please print or type this report, and fax or mail it to the appropriate MCO. · To determine the appropriate MCO, ask the injured worker or employer, visit www.bwc.ohio.gov or call 1-800-644-6292, and listen to the options. · If the injured worker is employed by a self-insuring employer, complete this form, and mail or fax it to the self-insuring employer. · You can obtain additional copies of this form on www.bwc.ohio.gov or by calling 1-800-644-6292 and listening to the options. Patient name BWC allowed condition(s) (DSM, IV, Axis) being treated Period of treatment dates: From: ________________________ To: ________________________ Duration/Length 30 minutes 1 hour 1.5 hours Modalities Other ____________________________________________________ Treatment frequency and duration Claim number Treatment Supportive Cognitive behavioral Psychodynamic Medication Other ___________________________________ Medication prescription and monitoring: Symptoms during service: Anxiety Depression Mania behavioral Disturbances Substance use Somatic Dissociation Sexual Sleep Impulse control problems Other ___________________________________ Prognosis: Progress: Good No change Fair Poor Worsened Improved Approaching complete Complete N/A-initial Psychotic Retardation Organic Learning Plan/Goals (indicate barriers, if applicable): Attach additional sheet if necessary. Functional status Please provide additional summary information regarding functional status and/or the ability to remain/return to work or any other information. Attach additional sheet if necessary. Mental health provider name (please print or type) Mental health provider's signature BWC-3917 (Rev. 7/13/2010) Date MEDCO-16 American LegalNet, Inc. www.FormsWorkFlow.com