BP-A0519

FEB 11
U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISON

PSYCHOLOGYSERVICESINMATEQUESTIONNAIRE
FirstName:
RegisterNumber:

LastName:

TodaysDate:

Gender:
___Male___Female
Instructions:PleasecircleNOorYESinresponsetoitems1through14below.IfyoucircleYES,provideadditionalinformationas
requested.Answereachitemhonestlytoensureyoureceivethepsychologicalservicesyoumayneed.
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Haveyoueversufferedfromorreceivedtreatmentforamentalillness?

IfYES,whatyear(s)?_______________Whatcondition/diagnosis?_______________________________
Haveyouevertakenorbeenprescribedmedicationtotreatamentalillness?

IfYES,whatyear(s)?_______________Whatmedication(s)?____________________________________
Haveyoueverreceivedmentalhealthtreatmentinahospitalemergencyroom?

IfYES,howmanytimes?____________
Haveyoueverbeenadmittedtoahospitalformentalhealthtreatment?

IfYES,howmanytimes?____________
Haveyoueverseriouslyconsideredharmingorkillingyourself?

IfYES,whatyear(s)?________________How?_______________________________________________
Haveyoueverattemptedtoharmorkillyourself?

IfYES,whatyear(s)?________________How?_______________________________________________
Areyouthinkingofharmingorkillingyourselfnow?
IFYES,ITISIMPORTANTTOLETUSKNOWSOWECANPROVIDEYOUWITHCOUNSELINGANDSUPPORT.
Haveyoubeenavictimofasexualassaultwhileincarcerated?
Haveyoucommittedasexualassaultwhileincarcerated?
Hasyouruseofalcoholordrugsevercreatedproblems foryou?
Whichofthefollowingdrugshaveyouused?
___alcohol___amphetamines/speed___cocaine/crack___ecstasy/clubdrugs
___heroin/opiates___inhalants___LSD/psychedelics___marijuana
___PCP___sedatives___tranquilizers___Other:____________
Areyoucurrentlywithdrawingfromalcoholordrugs(detoxing)?

IfYES,whatdrug(s)?_____________________________Whendidyoulastuse?__________________
Doyouwishtoparticipateindrugabusetreatment?

Areyoucurrently: A.sad,tearful,depressed?
B.tense,nervous,anxious?
C.feelinghopelessaboutlife?
D.hearingvoicesorseeingthingsothersdonot?
Doyouwishtoseeamentalhealthproviderwhileatthisfacility?

NO

YES

NO

YES

NO

YES

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YES

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YES

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YES
YES
YES

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YES

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YES
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YES

INMATESIGNATURE:__________________________________________________________DATE:______________________

STAFFUSEONLY
MHCareLevel:CARE1MHCARE2MHCARE3MHCARE4MHPSYALERT:NOYES

DX:CURRENTMEDS:

FollowUp:NOYESFollowUpServices:DAPMHPsychologyMHPsychiatrySOTPPREAOther:

BP-A0519
FEB 11
U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISON

CuestionariodelDepartamentodeServiciosdePsicologaparaReos
Nombre:
NmerodeRegistro:

Apellido:

Fecha:

Gnero:
___Masculino___Femenino
Instrucciones:FavordeindicarconuncrculoSoNoenrespuestaalaspreguntasdel1al14msabajo.SiustedindicaqueS,
incluyalainformacinsolicitada.Contestecadapreguntahonestamenteparagarantizarlelosserviciospsicolgicosquenecesita.

S
NO
1
Algunavezhasufridoorecibidotratamientopara una enfermedadmental?

SiindicqueS,enquao(s)?_______________Culfuelacondicin/diagnstico?______________
2
Algunavezhatomadoolehanrecetadomedicamentosparaeltratamientodeunaenfermedadmental?
S
NO
SiindicqueS,enquao(s)?_______________Qumedicamentos?___________________

3
Algunavezharecibidotratamientodesaludmentalenla saladeemergenciasdeunhospital?
S
NO

SiindicqueS,cuntasveces?____________
4
Algunavezhasidoadmitidoaunhospitalparatratarseunproblemadesaludmental?
S
NO

SiindicqueS,cuntasveces?____________
5
Algunavez,haconsideradoseriamentehacersedao oquitarselavida?
S
NO

SiindicqueS,enquao(s)?________________Cmo?_______________________________
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Algunavez,haintentadohacersedaooquitarselavida?
S
NO

SiindicqueS,enquao(s)?________________Cmo?_______________________________
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Actualmenteconsiderahacersedaooquitarselavida?
S
NO
SIINDICQUES,ESIMPORTANTEDEJARNOSSABERPARAQUEPODAMOSPROVEERLECONSEJERAY

AYUDA.
8
Hasidounavctimadeataquesexualmientrashaestadoencarcelado?
S
NO
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Hacometidounataquesexualmientrashaestadoencarcelado?
Algunavezlehacreadoproblemaselusode alcoholodrogas?
Culdelassiguientesdrogashausado?

S
S

NO
NO

NO

S
S
S
S
S

NO

___alcohol___anfetaminas/speed___cocana/crack___ecstasy/drogasdefiestasnocturnas
___herona/opiceos___inhalantes___LSD/psicodlicas___marijuana
___PCP___sedantes___tranquilizantes___Otro:______________

11

Actualmenteseestalejandodelalcoholodelasdrogas(desintoxicndose)?

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SiindicqueS,qudroga(s)?___________________Cundola(s)usporltimavez?____________
Deseaparticipareneltratamientodeabusodedrogas?
Actualmenteestusted: A.triste,lloroso, deprimido?
B.tenso,nervioso,ansioso?
C.sintindosedesesperanzadoantelavida?
D.escuchandovocesoviendocosasqueotrosnoven?
Deseaverunproveedordesaludmentalmientras est enesta instalacin?

FIRMADELREO:__________________________________________________________FECHA:______________________

STAFFUSEONLY
MHCareLevel:CARE1MHCARE2MHCARE3MHCARE4MHPSYALERT:NOYES

DX:CURRENTMEDS:
FollowUp:NOYESFollowUpServices:DAPMHPsychology MHPsychiatrySOTPPREAOther:

NO
NO
NO
NO
NO