Behavioral Observations Affect Blunted Constricted Normal ☐Flat ☐ ☐ ☐ ☐Broad Facial Expression Vacant ☐ Blank ☐ Strained ☐ ☐Pained Grimacing ☐ Smiling ☐ Other ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Summary & Recommendations Additional Comments: Based on the data gathered for the current Pre Evaluation Screening: It is NOT recommended that this respondent receive a civil commitment exam. ☐ 1) Current available information indicates that present symptomatology is due to Disability Epilepsy Dependency ☐ ☐Chemical Illness ☐Mental 2) The following referrals for appropriate evaluation or treatment have been provided: a. b. c. It IS recommended that this respondent receive a civil commitment exam. Based on the data available for the ☐ current Pre Screening Evaluation the following symptomatology cannot be managed/treated in a less restrictive environment: 1) 2) 3) 4) Signature-Credentials
Behavioral Observations Affect ☐Flat ☐ Blunted ☐ Constricted ☐ Normal ☐Broad Facial Expression ☐ Vacant ☐ Blank ☐ Strained ☐Pained ☐ Grimacing ☐ Smiling ☐ Other Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Summary & Recommendations Additional Comments: Based on the data gathered for the current Pre Evaluation Screening: ☐ It is NOT recommended that this respondent receive a civil commitment exam. 1) Current available information indicates that present symptomatology is due to Disability ☐ Epilepsy ☐Chemical Dependency ☐Mental Illness 2) The following referrals for appropriate evaluation or treatment have been provided: a. b. c. ☐ It IS recommended that this respondent receive a civil commitment exam. Based on the data available for the current Pre Screening Evaluation the following symptomatology cannot be managed/treated in a less restrictive environment: 1) 2) 3) 4) Signature-Credentials