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Telemedicine Consent
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Appointment Type
• • •
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Comments
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Presenting Concerns
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Suicidal/Homicidal Ideation
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Have you ever tried to harm or kill yourself?
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Was your intent to die?
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Action Taken?
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Suicidal Ideation Frequency
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How many times in your life has this occurred?
• • •
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Intent/Plan Verbal Contract
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Intent/Plan Comments
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Mental Status
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Appearance
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Appearance Comments
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Behavior
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Behavior Comments
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Speech
• • •
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Speech Comments
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Language
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Language Comments
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Knowledge
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Knowledge Comments
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Judgement
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Judgement Comments
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Orientation
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Orientation Comments
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Mood
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Mood Comments
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Affect
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Affect Comments
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Attn/Conc
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Attn/Conc Comments
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Memory
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Memory Comments
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Thought Process
• • •
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Thought Processes Comments
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Thought Content
• • •
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Thought Content Comments
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Intervention(s) Used
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Clinical Impressions
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Plan
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Plan
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Follow-Up
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Follow Up Appointment Date/Comments
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No Follow-Up Scheduled
• • •
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No Follow-Up Scheduled Comments
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Time Spent
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