Form I-18 "Mental Health Treatment Report - Outpatient" - New York

What Is Form I-18?

This is a legal form that was released by the New York State Office of Victim Services - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New York State Office of Victim Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I-18 by clicking the link below or browse more documents and templates provided by the New York State Office of Victim Services.

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Download Form I-18 "Mental Health Treatment Report - Outpatient" - New York

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ANDREW M. CUOMO
ELIZABETH CRONIN ESQ.
Governor
Director
MENTAL HEALTH TREATMENT REPORT – OUTPATIENT
DATE OF REPORT:
PATIENT INFORMATION
NAME:
CLAIM NO.:
ADDRESS:
DATE OF BIRTH:
SEX:
MALE
FEMALE
TELEPHONE: (
)
DATE OF CRIME:
MARITAL STATUS:
/
/
DATE TREATMENT BEGAN:
CONTINUING:
YES
NO
TERMINATED:
/
/
DIAGNOSIS (USE D.S.M. IV)
1.
4.
2.
5.
3.
6.
PLEASE RESPOND TO ALL ITEMS – USE ADDITIONAL PAGES IF NECESSARY
I
1. State the claimant/victim’s initial reasons for seeking treatment. Describe how and when the condition was first
manifested. Summarize previous treatment efforts, if any.
2. Please describe, in detail, the relationship between the crime and the need for treatment.
*I-18*
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210 │ 800-247-8035 │www.ovs.ny.gov
ANDREW M. CUOMO
ELIZABETH CRONIN ESQ.
Governor
Director
MENTAL HEALTH TREATMENT REPORT – OUTPATIENT
DATE OF REPORT:
PATIENT INFORMATION
NAME:
CLAIM NO.:
ADDRESS:
DATE OF BIRTH:
SEX:
MALE
FEMALE
TELEPHONE: (
)
DATE OF CRIME:
MARITAL STATUS:
/
/
DATE TREATMENT BEGAN:
CONTINUING:
YES
NO
TERMINATED:
/
/
DIAGNOSIS (USE D.S.M. IV)
1.
4.
2.
5.
3.
6.
PLEASE RESPOND TO ALL ITEMS – USE ADDITIONAL PAGES IF NECESSARY
I
1. State the claimant/victim’s initial reasons for seeking treatment. Describe how and when the condition was first
manifested. Summarize previous treatment efforts, if any.
2. Please describe, in detail, the relationship between the crime and the need for treatment.
*I-18*
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210 │ 800-247-8035 │www.ovs.ny.gov
3. Does the claimant/victim have a history of a pre-existing psychiatric disorder?
Yes
No
If yes, please describe that disorder, reasons(s) for treatment, type(s) of treatment and date(s).
4. What percent of the current mental health treatment is causally-related to the date of crime for which this claim is
based? Check the percentage that applies or indicate another percentage. This must be completed.
0%
25%
50%
75%
100% Other: _________
5. In your opinion, would the claimant/victim be in treatment if it weren’t for the crime?
6. Describe the claimant/victim’s current condition. Include the duration and severity of functional impairments and
stress factors and the period of disability from employment.
Date disability began:
/
/
Date disability ended:
/
/
7. Please describe current causally-related treatment goals and estimated duration of treatment to achieve stated goals.
II
COMPONENTS OF TREATMENT PLAN
1. Psychotherapy: Specify types, frequency and length of sessions (if group therapy, also give number of patients in
group).
2. Medication: Please list only causally-related medications that are needed as a direct result of the crime.
3. Adjunctive therapies: (e.g. physical or occupational therapy). Specify type, frequency and duration.
4. If psychotherapy sessions are more than two (2) per week provide rationale.
Other remarks or additional detail that would assist professional reviewer in understanding this claim.
III
Prognosis:
IV
SIGNATURE OF PROVIDER
DATE
PROVIDER INFORMATION
NAME:
LICENSE #:
ADDRESS:
AGENCY:
SOCIAL SECURITY #:
TELEPHONE #:
(
)
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