![](media/image1.png){width="0.9375in" height="0.9375in"}

> In reply refer to:

November 2007

Dear Colleague:

> Thank you for your interest in the Women\'s Trauma Recovery Center
> (WTRC), a residential rehabilitation treatment program for PTSD
> resulting from military sexual trauma. Enclosed is the newest referral
> packet for admission of female veterans to our residential program.
> **Please discard any old referral packets** and feel free to make
> copies of this edition.
>
> The WTRC at the Central Texas Veterans Health Care System provides
> state-of-the-art diagnostic assessment and evaluation of female
> veterans who experienced sexual trauma while serving in the military.
> Evidence based treatment for PTSD, and best practices, are conducted
> at the WTRC. As noted on the *Treatment Agreement,* all veterans are
> admitted for a period of 7-weeks.
>
> ***Please note that referral packets*** ***must be completed by the
> referring clinician*** and ***not by the veteran***. A
> multidisciplinary team reviews referral packets; ***incomplete packets
> will not be processed. When data is missing, you will be asked to
> provide that information; screening will be delayed until all
> necessary data is received.***
>
> When deciding whether to refer a veteran to the WTRC, please keep
> these Admission Criteria in mind:

-   History of military sexual trauma,

-   At least 6 months post most recent sexual trauma,

-   The veteran's current problems must be due, primarily, to military
    sexual trauma,

-   The veteran must be substance free for at least 30 days,

-   The veteran must be 30 days post discharge for acute inpatient
    mental health,

-   Referral from a Mental Health provider who judges that the patient
    is likely to benefit from treatment and whom completes the
    application with the patient,

-   Commitment and plan for post-discharge continuing care and stability
    of living environment,

-   Ability to live independently and to interact appropriately with
    others,

-   The veteran has had some mental health treatment that has proven to
    be insufficient, and

-   The veteran must be able to actively participate in group treatment
    in a residential rehabilitation setting.

> Exclusionary criteria include:

-   Active psychotic symptomatology,

-   Significant cognitive impairment,

-   Unresolved legal issues and charges (i.e., no pending court dates
    and/or issues around which a legal decision has yet to be rendered),

-   Presents a danger to self/others,

-   Major medical problems that will either prevent patient from full
    participation or require extraordinary medical monitoring (Note: A
    physical prior to referral and included in the packet will expedite
    the medical clearance aspect of screening), and

-   History of perpetrating acts of sexual assault or violence against
    others.

> Please include with the *Referral Information* a ***copy of the
> veteran\'s DD214 (military discharge papers), a signed Treatment
> Agreement*,** and any other material that you feel would be useful.
> Please provide a copy of results of any psychological or
> neuropsychological testing completed by the veteran within the past
> two years.
>
> If you have questions regarding referrals, please contact: Debra
> Guenzel, Program Support Assistant
>
> Phone: (254) 743-1711
>
> Applications can be securely **faxed to (254) 743-1807**

## Women's Trauma Recovery Center (WTRC)

Central Texas Veterans Health Care System

**Referral Information**

<table style="width:100%;">
<colgroup>
<col style="width: 35%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><strong>Referring Clinician:</strong></td>
<td colspan="4"><strong>VISN#:</strong></td>
<td colspan="3"><p><strong>Phone:</strong></p>
<p>( ) -</p></td>
</tr>
<tr class="even">
<td colspan="9"><strong>Agency/Organization:</strong></td>
<td colspan="3"><p><strong>FAX:</strong></p>
<p>( ) -</p></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Email Address:</strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>Name of Veteran:</strong></td>
<td colspan="6"><p><strong>SSN:</strong></p>
<p>______ - ______ - ______</p></td>
<td colspan="3"><p><strong>DOB:</strong></p>
<p>____ /____ /____</p></td>
<td><p>Gender:</p>
<p> Male</p>
<p> Female</p></td>
</tr>
<tr class="odd">
<td colspan="9"><strong>Veteran Address:</strong></td>
<td colspan="3"><p><strong>Veteran Phone:</strong></p>
<p>( ) -</p></td>
</tr>
<tr class="even">
<td colspan="2"><p><strong>Ethnicity:</strong></p>
<p> Asian / Pacific Islander</p>
<p> African American</p>
<p> Hispanic / Latino American</p>
<p> Caucasian</p>
<p> Native American</p>
<p> Mixed Ethnicity ________________</p>
<p> Other (list)</p></td>
<td colspan="5"><p><strong>Marital Status:</strong></p>
<p> Never Married</p>
<p> Married</p>
<p> Domestic Partner</p>
<p> Separated</p>
<p> Divorced</p>
<p> Widowed</p>
<p># Children:</p></td>
<td colspan="5"><p><strong>Branch of Service</strong>:</p>
<p> Army  Navy</p>
<p> Air Force  Marines</p>
<p> Coast Guard</p>
<p><strong>Service Connection:</strong></p>
<p> Yes  No If Yes: _____ %</p>
<p>For:________________________</p></td>
</tr>
<tr class="odd">
<td colspan="2"><p><strong>Service Dates:</strong></p>
<p><strong>From: To:</strong></p>
<p>/ / / /</p></td>
<td colspan="5"><p><strong>Warzone Dates:</strong> 
<strong>N/A</strong></p>
<p><strong>From: To:</strong></p>
<p>/ / / /</p></td>
<td colspan="5"><p><strong>Military Jobs:</strong></p>
<p>___________________________</p></td>
</tr>
<tr class="even">
<td><p><strong>Theatre:</strong></p>
<p> Korea  Persian Gulf</p>
<p> Vietnam  Iraqi Freedom</p>
<p> Panama  Afghanistan</p>
<p> Grenada  Other</p></td>
<td colspan="2"><p><strong>POW:</strong></p>
<p> Yes</p>
<p> No</p></td>
<td colspan="3"><p><strong>Decorations:</strong></p>
<p> Purple Heart</p>
<p> CIB</p>
<p> CAB</p>
<p> Other ____</p></td>
<td colspan="4"><p><strong>Disciplinary:</strong></p>
<p> Article 15</p>
<p> Court Marshal</p></td>
<td colspan="2"><p><strong>Discharge:</strong></p>
<p> Honorable</p>
<p> General</p>
<p> Medical</p>
<p> Other</p></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Current Psychiatric Diagnoses:</strong></td>
</tr>
<tr class="even">
<td colspan="4">Axis I:</td>
<td colspan="8">Axis III:</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="4">Axis II:</td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="12">Please describe your clinical experience with this
veteran. Why are you recommending residential rather than continued
outpatient treatment? What issues have been raised in treatment, and how
do they relate to the veteran’s disability? <em>(<strong>Please list
Criterion A/war zone stressors)</strong></em></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
</tbody>
</table>

+----------+-------------+------+---+-----------+-------------------+
| **Psy    |             |      |   |           |                   |
| chiatric |             |      |   |           |                   |
| T        |             |      |   |           |                   |
| reatment |             |      |   |           |                   |
| H        |             |      |   |           |                   |
| istory** |             |      |   |           |                   |
|          |             |      |   |           |                   |
| *(If     |             |      |   |           |                   |
| hosp     |             |      |   |           |                   |
| italized |             |      |   |           |                   |
| in past  |             |      |   |           |                   |
| 2 years, |             |      |   |           |                   |
| please   |             |      |   |           |                   |
| attach   |             |      |   |           |                   |
| hospital |             |      |   |           |                   |
| d        |             |      |   |           |                   |
| ischarge |             |      |   |           |                   |
| sum      |             |      |   |           |                   |
| maries)* |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **T      |             |      |   |           |                   |
| reatment |             |      |   |           |                   |
| Hi       |             |      |   |           |                   |
| story:** |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Appro    |             |      |   |           |                   |
| ximately |             |      |   |           |                   |
| how many |             |      |   |           |                   |
| sessions |             |      |   |           |                   |
| of       |             |      |   |           |                   |
| ou       |             |      |   |           |                   |
| tpatient |             |      |   |           |                   |
| mental   |             |      |   |           |                   |
| health   |             |      |   |           |                   |
| t        |             |      |   |           |                   |
| reatment |             |      |   |           |                   |
| has the  |             |      |   |           |                   |
| veteran  |             |      |   |           |                   |
| received |             |      |   |           |                   |
| in the   |             |      |   |           |                   |
| **[past  |             |      |   |           |                   |
| year     |             |      |   |           |                   |
| ]{.under |             |      |   |           |                   |
| line}**? |             |      |   |           |                   |
|          |             |      |   |           |                   |
|  None  |             |      |   |           |                   |
| 1-6     |             |      |   |           |                   |
| 7-12    |             |      |   |           |                   |
| 13-26   |             |      |   |           |                   |
| 26-52   |             |      |   |           |                   |
| 53+      |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Appro    |             |      |   |           |                   |
| ximately |             |      |   |           |                   |
| how many |             |      |   |           |                   |
| days of  |             |      |   |           |                   |
| i        |             |      |   |           |                   |
| npatient |             |      |   |           |                   |
| psy      |             |      |   |           |                   |
| chiatric |             |      |   |           |                   |
| hospita  |             |      |   |           |                   |
| lization |             |      |   |           |                   |
| has the  |             |      |   |           |                   |
| veteran  |             |      |   |           |                   |
| received |             |      |   |           |                   |
| in the   |             |      |   |           |                   |
| **[past  |             |      |   |           |                   |
| year     |             |      |   |           |                   |
| ]{.under |             |      |   |           |                   |
| line}**? |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -   None |             |      |   |           |                   |
|         |             |      |   |           |                   |
|     1-7  |             |      |   |           |                   |
|         |             |      |   |           |                   |
|     8-30 |             |      |   |           |                   |
|         |             |      |   |           |                   |
|          |             |      |   |           |                   |
|    31-60 |             |      |   |           |                   |
|         |             |      |   |           |                   |
|          |             |      |   |           |                   |
|   61-180 |             |      |   |           |                   |
|         |             |      |   |           |                   |
|     181+ |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **Trauma |             |      | * |           |                   |
| Hi       |             |      | * |           |                   |
| story:** |             |      | M |           |                   |
|          |             |      | e |           |                   |
|  Sexual |             |      | d |           |                   |
| Assaul   |             |      | i |           |                   |
| t/Trauma |             |      | c |           |                   |
| During   |             |      | a |           |                   |
| Active   |             |      | t |           |                   |
| M        |             |      | i |           |                   |
| ilitary. |             |      | o |           |                   |
|          |             |      | n |           |                   |
|  Sexual |             |      | L |           |                   |
| Assaul   |             |      | i |           |                   |
| t/Trauma |             |      | s |           |                   |
| as a     |             |      | t |           |                   |
| C        |             |      | / |           |                   |
| ivilian. |             |      | D |           |                   |
|          |             |      | o |           |                   |
|         |             |      | s |           |                   |
| Witness  |             |      | e |           |                   |
| to a     |             |      | : |           |                   |
| T        |             |      | * |           |                   |
| raumatic |             |      | * |           |                   |
| Event.   |             |      |  |           |                   |
|          |             |      | S |           |                   |
|         |             |      | e |           |                   |
| Physical |             |      | e |           |                   |
| Assault. |             |      | C |           |                   |
|          |             |      | P |           |                   |
|         |             |      | R |           |                   |
| C        |             |      | S |           |                   |
| hildhood |             |      |   |           |                   |
| Sexual   |             |      |   |           |                   |
| Abuse.   |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -   C    |             |      |   |           |                   |
| hildhood |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Physical |             |      |   |           |                   |
|          |             |      |   |           |                   |
|   Abuse. |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -        |             |      |   |           |                   |
| Domestic |             |      |   |           |                   |
|     V    |             |      |   |           |                   |
| iolence. |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -        |             |      |   |           |                   |
|    Rape. |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -        |             |      |   |           |                   |
|   Non-Co |             |      |   |           |                   |
| nsensual |             |      |   |           |                   |
|     Oral |             |      |   |           |                   |
|          |             |      |   |           |                   |
|   and/or |             |      |   |           |                   |
|     Anal |             |      |   |           |                   |
|          |             |      |   |           |                   |
|  Sodomy. |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -        |             |      |   |           |                   |
| Indecent |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Assault. |             |      |   |           |                   |
|          |             |      |   |           |                   |
| -   Or   |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Attempts |             |      |   |           |                   |
|     to   |             |      |   |           |                   |
|          |             |      |   |           |                   |
|   Commit |             |      |   |           |                   |
|          |             |      |   |           |                   |
|    These |             |      |   |           |                   |
|          |             |      |   |           |                   |
|    Acts. |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| *        |             |      |   |           |                   |
| *Suicide |             |      |   |           |                   |
| H        |             |      |   |           |                   |
| istory** |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Does the |             |      |   |           |                   |
| veteran  |             |      |   |           |                   |
| have a   |             |      |   |           |                   |
| history  |             |      |   |           |                   |
| of       |             |      |   |           |                   |
| suicidal |             |      |   |           |                   |
| i        |             |      |   |           |                   |
| deation? |             |      |   |           |                   |
|  No    |             |      |   |           |                   |
| Yes      |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Has the  |             |      |   |           |                   |
| veteran  |             |      |   |           |                   |
| made     |             |      |   |           |                   |
| suicide  |             |      |   |           |                   |
| a        |             |      |   |           |                   |
| ttempts? |             |      |   |           |                   |
|  No    |             |      |   |           |                   |
| Yes      |             |      |   |           |                   |
| Dates:   |             |      |   |           |                   |
| \_       |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
|          |             |      |   |           |                   |
| (Please  |             |      |   |           |                   |
| d        |             |      |   |           |                   |
| escribe) |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **S      |             |      |   |           |                   |
| ubstance |             |      |   |           |                   |
| Abuse    |             |      |   |           |                   |
| H        |             |      |   |           |                   |
| istory** |             |      |   |           |                   |
|          |             |      |   |           |                   |
| Has the  |             |      |   |           |                   |
| veteran  |             |      |   |           |                   |
| abused:  |             |      |   |           |                   |
|         |             |      |   |           |                   |
| Alcohol  |             |      |   |           |                   |
|         |             |      |   |           |                   |
| Illegal  |             |      |   |           |                   |
| Drugs   |             |      |   |           |                   |
| Med      |             |      |   |           |                   |
| ications |             |      |   |           |                   |
| ­\_\_     |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
| \_\_\_\_ |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **Drug** | **Use (more | **Nu |   | **\#      | **Treatment?**    |
|          | than 10     | mber |   | times per |                   |
|          | times in a  | mo   |   | week      | **DATE:**         |
|          | month)**    | nths |   | during    |                   |
|          |             | s    |   | last      |                   |
|          |             | ince |   | use**     |                   |
|          |             | last |   |           |                   |
|          |             | u    |   |           |                   |
|          |             | se** |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **A      |  Yes  No  |      |   |           |  Inpt  Outpt    |
| lcohol** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **Amphet |  Yes  No  |      |   |           |  Inpt  Outpt    |
| amines** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **Barbi  |  Yes  No  |      |   |           |  Inpt  Outpt    |
| tuates** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **Ca     |  Yes  No  |      |   |           |  Inpt  Outpt    |
| nnabis** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **C      |  Yes  No  |      |   |           |  Inpt  Outpt    |
| ocaine** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| *        |  Yes  No  |      |   |           |  Inpt  Outpt    |
| *Halluci |             |      |   |           |                   |
| nogens** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| *        |  Yes  No  |      |   |           |  Inpt  Outpt    |
| *Opiates |             |      |   |           |                   |
| (H       |             |      |   |           |                   |
| eroin)** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **PCP**  |  Yes  No  |      |   |           |  Inpt  Outpt    |
+----------+-------------+------+---+-----------+-------------------+
| **Pres   |  Yes  No  |      |   |           |  Inpt  Outpt    |
| cription |             |      |   |           |                   |
| Abuse**  |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **       |  Yes  No  |      |   |           |  Inpt  Outpt    |
| Other:** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
| **COM    |             |      |   |           |                   |
| MENTS:** |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+
|          |             |      |   |           |                   |
+----------+-------------+------+---+-----------+-------------------+

+---------------------------------------------------------+------------+
| **Legal History**                                       |            |
|                                                         |            |
| *(We cannot accept anyone with outstanding legal        |            |
| charges or who are mandated to be in treatment)*        |            |
+---------------------------------------------------------+------------+
| Has the veteran been incarcerated?  No  Yes (Please   |            |
| describe)                                               |            |
+---------------------------------------------------------+------------+
|                                                         |            |
+---------------------------------------------------------+------------+
| Is the veteran currently on probation/parole?  No     |            |
| Yes (Please describe)                                   |            |
+---------------------------------------------------------+------------+
|                                                         |            |
+---------------------------------------------------------+------------+
| Additional Legal Information:                           |            |
+---------------------------------------------------------+------------+
|                                                         |            |
+---------------------------------------------------------+------------+
|                                                         |            |
+---------------------------------------------------------+------------+
|                                                         |            |
+---------------------------------------------------------+------------+
| **Personal History**                                    |            |
+---------------------------------------------------------+------------+
| Pre-Military                                            |            |
+---------------------------------------------------------+------------+
| History of Mental Illness in family?                    |  No  Yes |
+---------------------------------------------------------+------------+
| Professional counseling prior to military?              |  No  Yes |
+---------------------------------------------------------+------------+
| History of disruptive or antisocial behavior?           |  No  Yes |
+---------------------------------------------------------+------------+
| Victim of childhood physical abuse?                     |  No  Yes |
+---------------------------------------------------------+------------+
| Victim of childhood sexual abuse?                       |  No  Yes |
+---------------------------------------------------------+------------+
| Victim of sexual assault?                               |  No  Yes |
+---------------------------------------------------------+------------+
| Post-Military                                           |            |
+---------------------------------------------------------+------------+
| History of violent acting out or antisocial behavior?   |  No  Yes |
+---------------------------------------------------------+------------+
| Victim of sexual assault?                               |  No  Yes |
+---------------------------------------------------------+------------+
| Victim of domestic violence?                            |  No  Yes |
+---------------------------------------------------------+------------+
| **Current Status**                                      |            |
+---------------------------------------------------------+------------+
| Employment                                              |            |
|                                                         |            |
| Is veteran currently employed?  Yes  No               |            |
|                                                         |            |
| If employed: Status while in residential tx?            |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| If unemployed, \# months: \_\_\_\_\_\_\_\_\_ Source of  |            |
| income:                                                 |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\                           |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| Number of jobs in the last 2 years:                     |            |
| \_\_\_\_\_\_\_\_\_\_\_                                  |            |
|                                                         |            |
| Number of Jobs since military:  None  1-5  6-12     |            |
| 13-50  51+                                             |            |
|                                                         |            |
| Longest continuous employment at one job since          |            |
| military: \_\_\_\_\_\_\_\_\_ years \_\_\_\_\_\_\_\_\_   |            |
| months                                                  |            |
+---------------------------------------------------------+------------+
| **Family & Relationship Status**                        |            |
+---------------------------------------------------------+------------+
| Are there minor children in the veteran's care?         |  No  Yes |
+---------------------------------------------------------+------------+
| Can arrangements for care of children be made while     |  No  Yes |
| veteran is hospitalized?                                |            |
+---------------------------------------------------------+------------+
| Will family be able to meet financial obligations while |  No  Yes |
| veteran is in care                                      |            |
+---------------------------------------------------------+------------+
| **Transition Plan From WTRC Inpatient Program CTVHCS**  |            |
|                                                         |            |
| Identify who will be liaison for veteran returning to   |            |
| original referral                                       |            |
| source:\                                                |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| \_\_\_\_\_\_\                                           |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| Who will follow veteran for outpatient mental health?   |            |
|                                                         |            |
| \_\_\_\_\_\_\                                           |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| Where will veteran reside?                              |            |
| \_\_\_\_\_\_\_\_\_\_\_\_                                |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| \_\_\_\_\_\_\                                           |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
|                                                         |            |
| Who will follow veteran for medical issues?             |            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |            |
+---------------------------------------------------------+------------+

+-------------------------------------------------------+--------------+
| **Medical Problems Checklist**                        |              |
|                                                       |              |
| *(completed by referral source **[with]{.underline}** |              |
| veteran*)                                             |              |
|                                                       |              |
| Check boxes for positive responses and explain below  |              |
|                                                       |              |
| NOTE: All positive responses require explanation      |              |
+-------------------------------------------------------+--------------+
| 1\. Pain, numbness, weakness in joint or limb.        |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 2\. Blood in stool, urine, phlegm, vomit.             |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 3\. Head injury with loss of consciousness.           |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 4\. Stomach pain.                                     |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 5\. Chest pain.                                       |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 6\. Diabetes. (Current treatment, FBS result)         |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 7\. Hypertension.                                     |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 8\. Heart disease. (Specific DX, Cardio tests)        |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 9\. Positive skin test for TB. (Prophylactic TX?)     |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 10\. Cancer. (Site, treatment)                        |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 11\. Anemia. (within 1 mo CBC results, source)        |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 12\. Hepatitis. (Circle: A, B, C, E, other)           |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 13\. Nicotine addiction.                              |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 14\. Stomach ulcers. Active bleed? Hemocult?          |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 15\. Colitis.                                         |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 16\. Seizures.                                        |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 17\. Breathing problems. Asbestos exposure, COPD,     |  past 6     |
| PFT's                                                 | months       |
+-------------------------------------------------------+--------------+
| 18\. Hallucinations.                                  |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 19\. Bad memory problems.                             |  past 6     |
|                                                       | months       |
+-------------------------------------------------------+--------------+
| 20\. Impulses to harm self or others.                 | -   past 6   |
|                                                       |     months   |
+-------------------------------------------------------+--------------+
| 21\. Gynecological problems (irr. Bleeding, PMS,      | -   past 6   |
| absence of period, pelvic pain, etc.)                 |     months   |
+-------------------------------------------------------+--------------+

+-----------------------------------------------------------------------+
| # COMMENTS:                                                           |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| Is there a possibility of current pregnancy: YES NO                   |
|                                                                       |
| If YES, how many weeks as of referral? \_\_\_\_\_\_\_\_\_(current     |
| date)                                                                 |
|                                                                       |
| When was the last time the veteran received:                          |
|                                                                       |
| -   Complete physical exam: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (date; |
|     attach a copy of the note to the application)                     |
+-----------------------------------------------------------------------+
| Referring Clinician's Signature:                                      |
| \_\_\                                                                 |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                            |
+-----------------------------------------------------------------------+

> **TREATMENT AGREEMENT**
>
> **FOR THE WOMEN'S TRAUMA RECOVERY CENTER (WTRC)**
>
> **Central Texas Veterans Health Care System**

*[I. Specific guidelines for treatment:]{.underline}*

1.  You will be expected to participate in and attend all of your
    scheduled groups and activities.

2.  You cannot be admitted to the program if you are under the influence
    of any substance other than prescribed medications. **At least 30
    days abstinence from alcohol and illegal drugs** will be required
    prior to admission to the program.

3.  Substance abuse is not compatible with treatment and will result in
    discharge from the program. Random drug/alcohol screens may be
    utilized, given a domiciliary policy.

4.  Possession of weapons, physical violence, verbal abuse/or threats of
    violence will result in your discharge from the program.

5.  You must adhere to all aspects of your therapeutic regimen,
    including but not limited to individual therapy, group
    psychotherapy, practice assignment completion, and exercise and
    recreation programs.

6.  While you are a resident there are some restrictions on when you can
    leave the hospital grounds. You will be issued a program manual
    which explains this and other program policies.

*[II. Length of Treatment]{.underline}*

All veterans are admitted to the WTRC, for an absolute maximum of
7-weeks and then referred for continuing outpatient treatment with the
referring clinician. All veterans are expected to have a discharge plan
prior to admission.

I have read the Treatment Agreement. I understand the described
guidelines, endorse them, and will abide by them if accepted into the
program.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Veteran\'s signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Referring clinician\'s signature Date

While in treatment I am willing to consider participation in research
studies which have potential of improving care for other veterans with
PTSD  No  Yes Veteran signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_