ARCHIVED Call Center Screener (EPN)

ARCHIVED PAGE

This page has been archived. New link to this page can be found here.

Archived page will expire December 31, 2020.

epn_number

If we get disconnected, what is the best phone number for me to call you on?

epn_insurance

Select patient insurance from the options below.

KP Classic - Commercial [1]
KP DHMO - Deductible [2]
KP Medi-Cal [3]
Medicare [4]
Self-Funded [5]

epn_copay

Amount of Copay or Cost Share

epn_reason

What is the reason you would like to be seen?

epn_identity

Are you calling about yourself or someone else?

Self [1]
Spouse/Domestic Partner [2]
Significant Other [3]
Parent [4]
Child [5]
Legal Guardian [6]
Other [7]

epn_caller

Name of the person calling

epn_disclaimer

I’d like to inform you that I am not a clinical provider. However, I need to ask you some sensitive questions that will help determine the best clinical provider for you.

homicidfx

if_screened()

Over the last two weeks, how often have you had thoughts of harming someone else?

Choose one

Never [1]
Sometimes [2]
Often [3]

cssrs2

if suicide_alert = 1

In the past 30 days, have you actually had any thoughts of killing yourself?

Choose one

No [0]
Yes [2]

cssrs3

if cssrs2 = 2

In the past 30 days, have you been thinking about how you might do this?

Choose one

No [0]
Yes [3]

cssrs4

if cssrs2 = 2

In the past 30 days, have you had these thoughts and had some intention of acting on them?

Choose one

No [0]
Yes [4]

cssrs5a

if cssrs2 = 2

In the past 30 days, have you started to work out or worked out the details of how to kill yourself?

Choose one

No [0]
Yes [5]

cssrs6a

if suicide_alert = 1

Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Choose one

No [0]
Yes [6]

cssrs6b

If cssrs6a = 6

How long ago did you do any of these?

Choose one

Within the last three months [6]
Over three months ago [3]

alongepmh

How well have you been getting along emotionally?

Choose one

Quite poorly [1]
Fairly poorly [2]
So-so [3]
Fairly well [4]
Quite well [5]
Very well [6]

phq1

Over the last two weeks, how often have you been bothered by having little interest or pleasure in doing things?

Choose one

Not at all [0]
Several days [1]
More than half of the days [2]
Nearly every day [3]

phq2

Over the last two weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Choose one

Not at all [0]
Several days [1]
More than half of the days [2]
Nearly every day [3]

gad1

Over the last two weeks, how often have you been bothered by feeling nervous, anxious or on edge?

Choose one

Not at all [0]
Several days [1]
More than half of the days [2]
Nearly every day [3]

gad2

Over the last two weeks, how often have you been bothered by being unable to stop or control worrying?

Choose one

Not at all [0]
Several days [1]
More than half of the days [2]
Nearly every day [3]

managemh

Over the last two weeks, how well have you been able to manage your day-to-day life?

Choose one

Very poorly [1]
Fairly poorly [2]
Fairly well [3]
Very well [4]

epn_work

Are you either currently on disability for a mental health concern, or feel that you are struggling at work due to your mental health symptoms?

No [0]
Yes [1]

epn_work_disclaimer

I want to inform you that your appointment will be to assess you for an appropriate treatment plan and your provider will determine if time off work is necessary.

epn_workers_comp

Do you have an active Worker’s Comp claim?

No [0]
Yes [1]

epn_medication

Are you currently seeing a psychiatrist for psychiatric meds that you are seeking to adjust?

No [0]
Yes [1]

epn_list

Did the patient/caller indicate they were calling about any of the following? Check all that apply.

Autism or Developmental Disorder [1]
Eating Disorder [2]
Dementia [3]
Pediatric or Adolescent ADHD [4]
Adult ADHD [5]
Psych Testing [6]
Conservatorship Request [7]
Court Ordered Treatment [8]
Seeking Addiction Medicine Services [9]
None [0]

epn_assistance

Will you require physical assistance at the therapy site?

No [0]
Yes [1]