Electroconvulsive Therapy | Centennial Peaks Hospital

Section 1 – Intake
1. Client has been on 3 or more separate antidepressants, mood stabilizers, or antipsychotics during their lifetime?
- NO
- YES
2. Personal or Family history of ECT?
- NO
- YES
Send Positive Screen with patient packet to unit for Treatment Team review

Section 2 – Social Work/Case Management – Complete for All Positive Screens
1. Treatment team to present ECT consult option to the patient
2. If patient is interested in consult:
3. Social Worker/Case Manager to complete the below:
a. Identify patient insurance:
b. Does the patient have stable living arrangement and support person to care for them post ECT:
- NO
- YES
c. Who is the patient's attending:
Phone:
d. Which unit is the patient on (unit):
Phone:
e. Referring Social Worker (name):
Phone:
f. Have patient sign ROI for Centennial Peaks Hospital ECT
g. Fax this completed screen and ROI to 303-666-2353
i. An ECT Liaison team will call and complete an initial consult to collect additional patient information, before a formal provider consult occurs.

Section 3 – CPH ECT Patient Navigator
Screen Follow-Up Form
1. Client has been on 3 or more separate antidepressants, mood stabilizers, or antipsychotics during their lifetime?
(For each med the patient has been on complete 1a & 1b)
- NO
- YES
Has the patient ever been on more than one psychotropic at the same time?
Mark below which medications the patients been on for 4 weeks or longer
- NO
- YES
Which:
2. While on a medication has the client had a period of time of at least 6 months in remission?
- NO
- YES
Which:
Appropriate for MD Consult:
- Criteria Not Met
- Consult Recommended
Consult Staff signature:
Date
Date Format: MM slash DD slash YYYY
Time

: HH

MM

MEDICATION HISTORY: medications tried in the past, but are NOT currently taking:
Antidepressants
MAOI
- Emsam (selegiline)
- Nardil (phenelzine)
- Parnate (tranylcypromine)
Duration of Use (weeks)
Reason Stopped (on own, SE, No effect, etc.)

Stimulants
- Adderall (amphetamine & dextroamphetamine)
- Dexadrine (dextroamphetamine)
- Ritalin (methyphenidate)
Duration of Use (weeks)
Reason Stopped (on own, SE, No effect, etc.)

Section 1 – Intake