|
Date of onset:
|
Date of onset:
|
|
2 Antidepressants (from 2 different classes)
|
FOR OPTUM: augmentation if no side effects; For MHN: within last 24 months
|
|
Medication Name
|
Medication Dose
|
|
Dates of Medication Trial
|
Ineffective? or Side Effects?
|
|
Medication Name
|
Medication Dose
|
|
Dates of Medication Trial
|
Ineffective? or Side Effects?
|
|
Medication Name
|
Medication Dose
|
|
Dates of Medication Trial
|
Ineffective? or Side Effects?
|
|
Medication Name
|
Medication Dose
|
|
Dates of Medication Trial
|
Ineffective? or Side Effects?
|
|
Diagnosis
|
Other or Additional Diagnosis
|
|
PHQ-9 Score (20+)
|
PHQ- 9 Score:
|
|
Previous/ Current Therapist
|
Therapist Name & Licensure (if applicable)
|
|
Ineffective Therapy Trial
|
Declined ECT
|
|
Risk/ Benefits Statement
|
Other Considerations?
|
