Centre: | ||
Department: | ||
Name of professional/intaker | ||
Name of patient | ||
BSN number of patient | ||
Yes/No | Value or finding | |
1. Severe negative affect with disadaptive coping | Yes | |
No | ||
2. Severe destructive behavior to oneself or others | Yes | |
No | ||
3. Multiple comorbid disorders on axis I and/or axis II due to severe psychiatric problems | Yes | |
No | ||
4. Severe social and societal disfunction: GAF≤50 | Yes | |
No | ||
5. Severe chronic traumatisation in childhood | Yes | |
No | ||
6. Difficulties in developing a therapeutic relationship | Yes | |
No | ||
NAa | ||
7. Treatment in specialized care was not successful | Yes | |
No | ||
NA | ||
Number of times positively scored (=YES) Score ≥4? | Yes -> Go to question 8 | |
No-> Not referred to highly specialized care based on this decision tool | ||
8. Possibility and motivation to conform to minimal treatment conditions for psychotherapy in intensive (day)care | Yes -> Referred to highly specialized care based on this decision tool | |
No-> Not referred to highly specialized care based on this decision tool | ||
NA-> Referred to highly specialized care based on this decision tool |