Bariatric Mental Assessment, Evaluation and Letter – Still Waters Professional Counseling Services, Inc.

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BARIATRIC MENTAL ASSESSMENT, EVALUATION, AND LETTER

The following is a required bariatric mental evaluation and assessment for morbid obesity for use in determining if the individual being assessed may receive insurance approval for bariatric surgery.

Date of Bariatric Evaluation

MM slash DD slash YYYY

Location of Service:

Home

Office

Telehealth

Other

INDIVIDUAL'S INFORMATION

"Individual" refers to the Patient Individual receiving Bariatric Psychiatric/Psychological Evaluation:

Name (Individual)

First Middle Last Suffix

Date of Birth (Individual)

Month

Day

Year

Legal Status (Individual)

Check all that apply.

Individual is of legal age of consent

Individual is under aged (18)

Individual is under the care of a custodial parent or legal guardian

Insurance Information (Individual)

Check the appropriate payer source.

Aetna

Amerigroup

BCBS

CareSource

Cenpatico

Cigna

DFCS

Medicaid

Self-Pay

Tri-Care

United Healthcare

Unknown

Insurance Policy Number

Gender (Indvidual)

Male

Female

Transgender

Unknown

Other

Marital Status (Individual)

Common Law

Married

Separated

Widowed

Divorced

Single

N/A

INDIVIDUAL'S CONTACT INFORMATION

Address (Individual)

Street Address City State / Province / Region ZIP / Postal Code

Phone (Individual)

Email (Individual)

EMERGENCY CONTACT

Name (Emergency Contact)

First Last Suffix

Phone (Emergency Contact)

INDIVIDUAL'S REASONS FOR SEEKING BARIATRIC SURGERY

Reason for seeking Bariatric Surgery

In individual's own words - state individual's reasons, goals ad expectations for seeking bariatric surgery.

Review and discuss

Realistic Expectations - that weight-loss surgery is a tool for weight loss and requires compliance to dietary and exercise regimes following the operation in order to lose weight and maintain weight loss over time. Mineral and Vitamin Supplement - that following weight loss surgery, they will be required to take mineral and vitamin supplements daily for life. Complications with Weight Loss Surgery that might be Life-Threatening - that there can be complications with weightless surgery that might be life-threatening.

Psychiatric & Medical History (Individual & Family)

A brief psychiatric and medical history indicating the individual's (patient's) baseline family structure including familial and psychiatric pathology and relationship with parent's, spouse, and children.

History and current eating disorders

History and current Psychiatric

History and current substance abuse

History and current medical and medications

Document if compliant with currently prescribed medications.

Still Waters Professional Counseling Services, Inc. (Still Waters) Bariatric Mental Health Assessment Final Letter

Still Waters Professional Counseling Services, Inc. 3711 Executive Center Dr. Augusta, GA 30907 Phone: 706-955-9224 Fax: 706-955-9349

Summary / recommendations:

Include any diagnosis and if the individual is recommended for surgery.

Name (Assessor)*

First Last License

Signature (Assessor)*

Signature Date (Assessor)*

MM slash DD slash YYYY

Email (Assessor)*

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