LODGED 

PROPOSED

Doc. 292-18

 (redacted)

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 1 of 179
EXHIBIT Q

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 2 of 179
COP 015222

Ciox Health 

P.O. Box 409740 

Atlanta, Georgia 30384-9740 

Fed Tax ID 58 - 2659941 

1-800-367-1500 

CiOX 

HEALTH 

INVOICE 

Invoice #: 

Date: 

Customer#: 

0298295912 

02/12/2020 

1787081 

,n••-n••u••••••u•n•••••••••••u••••••u••n••••••••••u••••••u••n••••••••••u••••••u••n•••• •••••uunn••••nunn••••uunn••1 

' ' ' ' 

! .. ShiP .. to.: .......................................................................................................... ! 

1••••••••••u••••••n••n••••••••••u••••••n••n••••••••••u••••••n••n•••••n••n••••••u••n••••••n••n••••••u••n••••••n••n•••••••1 

' ' ' ' 

! .. Bill .. to.: ............................................................................................................... ! J..Records .. from = ................................................................................... ] 

OCONNOR AND CAMPBELL 

OCONNOR AND CAMPBELL 

7955 S PRIEST DR 

TEMPE,AZ 85284-1050 

OCONNOR AND CAMPBELL 

OCONNOR AND CAMPBELL 

7955 S PRIEST DR 

TEMPE,AZ 85284-1050 

Requested By: 

Patient Name: 

OCONNOR AND CAMPBELL 

MUHAYMIN MUHAMMAD ABDUL 

DOB: 

Desert ption 

TERROS MCDOWELL 

4909 E MCDOWELL RD 

PHOENIX,AZ 85008 

Quantity Unit Price Amount ,.,, .. ,,~---•u••···········•n••••nu••·····•n••••n••••nHMMHMMMMHMOMMHMMMMUHMMHMMMMHMOMM-••·····••u••·········•u••·····•u••·········•u••····••u••········••u••····••u••·········•u•••n•••u••·•·n••············•u••·················•nu••·····•n••·······•nu••······ ''"''"''''HNMHXOMMMM••••n••••H••••n••••uHMMHMMMMHMOMMHMMM ,,,,.,.,,.,,,m .. ,, ••••• ux••······ ···········•·n••·················· ''"""''"''"'"''''""""''HNMHXOMMMMMM«MOMMMMMMMHNMHXOMMMMH«MOMM 

' ' ' ' ' ' 

i Basic Fee i ! 43£ 75 

i Retrieval Fee I I 0.00 

Per Page Copy (Paper) 1 167 41.75 

Electronic Data Archive Fee 2.00 

Subtotal 87.50 

Sales Tax 7.09 

Invoice Total 94.59 

Balance Due 94.59 

I Terms: Net 30 days Please remit this amount: $~4.59(USD) ' ' ! 

'n•••--•••••n••••••••••n••••••n•wnn••••nnun••••n•wnn••••nnun••••n•wnn••••nnu-•n••••••nnuwnwwwuwwn••••••nnu-•n••••••n••••••••n••••n••••••n••••••••n••••n••••••n•••••••••••••n--n••n••••••n••n••••-••••n••nn••••n••n••••••n••nn••••-•••nnu•n•••n-•n••••••••n••••n••••••n••••••••-•••••••••••n••••••••n••••n••••••n••••••---••••nnnn••••n••nn••••nnnn••••n••nn••••nnn••••••n••n••••••nnn••••••n••nn~ 

----------------------------~-----------------------------------------------------------------------------------------------

Ciox Health 

P.O. Box 409740 

Atlanta, Georgia 30384-9740 

Fed Tax ID 58 - 2659941 

1-800-367-1500 

Get future medical records as soon as they are processed, 

by signing up for secure electronic delivery. 

Register at: https://edelivery.cioxhealth.com 

Please return stub with payment. 

Please include invoice number on check_ 

Invoice#: 0298295912 

Check# 

Payment Amount $ _______ _ 

To pay invoice online, please go to https://paycioxhealthtcom/pay/ or call 800-367-1500. 

Email questions to collections@cioxhealth_comt 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 3 of 179
COP 015223

A. f:rof essional Co~oratiory . . Attorneys .Licensed In 11:ultiple i.J11nsd1ctions 

October 31, 2019 

Terrost Inc~ 

c/o Quarles & Brady 

2 North Central Ave. 1 Suite 200 

Phoeni.x1 AZ 85004 

RE: Muhammad Abdul Muhaymin, Jr .. 

DOB: 

Dear Custodian of Records: 

VJdter's Contact lnforn1ation 

tiffany·~ gill@occlaw. con1 

602.241. 7028 

Enclosed is a Subpoena for Documents directing you to produce documents at this 

office. We DO NOT intend to take testimony at the deposition* We mere-ly want the 

documents stated in Exhibit uAn which is attached to the Subpoena~ .Enclosed with the 

Subpoena is an authorization signed by Mussalina Muhayminl as personal representatlve 

of the Estate of Muha.mmad Abdul Muhayminf Jr. 

If you prefer1 you may simply mail the documents to our office before the date set 

forth in the Subpoena~ Pl1rsuant to Arizona Revised Statutes, Section·:_12-351, payment 

will be made at the rate of $.25 per page of photocopying and $25 .. 00 per hour of 

clerical time necessary in locating and photocopying the records upon presentation 

of any itemized statement~ 

If! for any reasont you cannot mail the records requested priorto the date stated in 

the Subpoena.t or have questions regarding the Subpoena, please contact me directly prior 

to the date set forth in the Subpoena._ 

Kindest regards, 

Tiffany GiH 

Paralegal 

cc: David Chami 

Haytham Faraj 

-· -= -----·--------~-~------- 7955 South Priest Drive} Te1npe, Arizona 85284 •T'elephone 602.241.7000 •Facsimile 602.241, 7039 

V.leb address \Vilitw.occlaw.com 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 4 of 179
COP 015224

AO 8813 (Rev_ 02/14) Subpoena to Produce Documents, Infonnation, or Objects or to Permit lnspection of Premises in a Civil Action 

UNITED S'fA1'ES DISTRIC"I' COUR'f 

Mussalina Muhaymin, 

for the 

District of Arizona 

,---------~-

Plaintiff 

) 

) 

) 

) 

) 

) 

V, Civil Action No, CV-17-04565-PHX-SMB 

City of Phoenix, et al. 

·-·-·-·-·-·--------·-·-·-·-·-·-·-·-·-·-·-·-·-·--·-·-· --

To: 

Defendant 

SUBPOENA T() PRODUCI! DOCUMENl'S, IN~'ORMATION, OR OBJECTS 

OR TO .PERMI1' INSPECTION OF PREMISES IN A CIVIL ACTION 

Terres, Inc. 

------ . ___ ,,,_,_,,.,,,,_,,.,,,,_,,.,,_,_,,.,, . ., ____________ ~-~- "'"'"""'""""'""""'""""'""""'""""'""" -~~-~--·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-·----·--"""""'" "'" 

(lv'ame of"person to whom this subpoena is directed) 

111' Pro,!uction: YOU ARE COMMANDlcD to produce at the time, date, and place set forth belovv the following 

docu1nentsi electro11ically stored information, or objects, and to .permit inspection, copying, testing1 or sampling of the 

material: See Exhibit A 

., . ·-... ... ... ... ···---·' ---..... ,·················-------·· .. --······-···-···-···-···1 

Place: O'Connor & Dyet I Date and ''fime: 

~:~p!: ;~e;~~;!v: __ . _L _____ .. 11/15/2019100~a~--------·_J 

□ Inspection qf Premises: YOlJ ARE COMMANDED to pern1it entry onto the designated pren1ises, land, or 

other property possessed or controlled by you at the time, date,. and location set fo1th belo,:v, so that the requesting party 

rnay inspect, measure, survey, photograph, test, or srunple the property or any designated object or operation on it 

re-:--··"""'""'""'""'""'"'-""'""'" '". ---~-~-----------·---•"'"""'""""'""""'""""'""""'""" '"' """' 'D~a-te_an_ct~·=r~im-e·", ---·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-·-•-'-' ··-----'l 

L_.. .. .. .. .. ---------···················· .. --~----··· .................... --------

The following provisions of Fed. R. Civ, P. 45 are attached - Rule 45(c), relating to the place of compliance; 

Rule 45( d), relating to your protection as a person subject to a subpoena; and Rule 45( e) and (g), relating to your duty to 

respond to this subpoena and the potential consequences of not doing so. 

Date: 10/31/2019 J 

CLERK OFCO[IRT 

OR 

Signature of Clerk or Deputy Clerk 

The name, address, e-n1ail address, and telephoIJe nu1nber of the attorney representing (name qfparty) City of Phoenix, et 

·-·~··~· 

Karen Stillwell, O'Connor & Dyet, 7955 S, Priest Drive, Tempe, AZ 85284 602-241-7000 karen.stillwell@occlaw.com 

Notice to the person \Vho issues or requests this subpoena 

If this subpoena co1n1nands the production of documents} electronically stored information, or tangible things or the 

inspection of premises before trial, a notice and a copy of the subpoena 1nust be served on each party in this case before 

it is served on the person to whom it is directed. Fed, R. Civ. P. 45(a)(4). 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 5 of 179
COP 015225

AO 8813 (Rev. 02il4) Sabpoena to l'rodure Documents, lnfonnation, or Objects or to Pennit Inspection of Premises in a Civil Action (Page 2) 

Civil Artion No. CV-17-04565-PHX-SMB 

PROOF 01'' SER\'l(;E 

(This section should not be filed ,vith the court unless required by Ped. R. l'iv. P. 45.) 

I received this subpoena for (name of individual and firle, if any) 

on (date) 

0 I served the subpoena by delivering a copy to the named person as follows: 

--·-------

on (date) ; or 

0 I returned the subpoena tL-riexecuted because: 

Unless the subpoena was issued on behalf of the lJnited States) or one of its officers or agents, I have also 

tendered to the \Vitness the fees for one day)s attendance, and the mileage allowed by lav-1, in the amount of 

$ 

~1y fees are$ for travel and $ for services, for a total of$ 0.00 

I declare under penalty of perjury that this infonnation is true. 

!)ate: 

Server's signature 

-------~-.,·~""""~"""'~"""' __ _,,,_, ----------·-·-·-·-·-·-·-·-·-·-·-·-·-·-·--·-- ----

Printed name and title 

Server's address 

Additional information regarding atte1nptcd service, etc.: 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 6 of 179
COP 015226

I 

AO 88B (Rev. 02/J 4) Subpoena to Produce Documents, Information, or Objects or to Pennit Inspection of Premises in a Civil Action(Pagr 3) 

Federal Rule of Civil Procedure 45 (c), (d), (e), and (g) (Effective 12/1/13) 

(c) Place of Compliance, 

(1) For n Trial, Hearing, or Deptisition. A subpoena n1ay con1mand a 

person to attend a trial, hearing, or deposition only as follows: 

(A) within 100 miles of where the person resides, is employed, or 

regularly transacts business ln person; or 

(B) within the state where the person resides, is e-mployed, or regularly 

transacts business in person, ifthe person 

(i) is a party or a party's officer; or 

(ii) is com1nanded to attend a trial and would not incur substantial 

expense. 

(2) For Otlte1· DiseOJ'ery. A subpoena !nay conunand: 

(A) productiott of d()Cumcnl'>, electronically stored infomrntion. or 

tangible things at a placl!: within l 00 tniles of where tbe person resides, is 

employed, or regularly transacts business in person; and 

fB) inspection of prernises at the premises to be inspected. 

(d) Protecting n Per,~ou Subject to a Subpoena; Enforeemcnt. 

(1) Avoiding Undue Burden or l(<r:peuse; Sanctions. A party or attorney 

responsible for issuing and serving a subpoena n1ust take reasonable steps 

to avoid imposing unduo;; burden or expense on a person subjeet to the 

subpoena. The cou.ii for the district where compliance is required must 

enforce this duty and impose an appropriate sanction~whic11 rnay include 

lost earnings and reasonable attorney's tees---0n a party or attorney who 

fails to con1p!y. 

{2) Com111and to Produce itfuterialr or l'ennit Inspection. 

(A}Appearance ,\lot Required A person com1nanded to produce 

documeμts, electronically stored information, fJt tangible things, or to 

pennit the inspection ofpremises. need not appear in per.son at the place of 

production or inspection unless also cmnn1anded to appear for a deposition, 

hearirig, or trial. 

(B) Objections. A person commanded to produce dow'Umcnts or tangible 

things or to pennit inspection may serve on the party or attorney designated 

in the subpoena a ,vritten objection to inspecting, copying, testing, or 

sampling any or all of1he materials or to inspecting the pren1ises-··-0r tn 

producing electronically stored i11formation in the form or furms requested. 

The objection nmst be served before the earlier of the time specified for 

cmnplim1cc or 14 days after !lie subpoena is served. J fan objection is n1ade, 

the follow"ing n1lcs apply: 

(i) At any time, on notice to the commanded pt1rson, the serving party 

may move the court for the d-istric.t where compliance is required f◊r an 

order compelling producti011 or inspection. 

(ii) These acts may be. required only as directed in the order, and the 

order nmst protect a person who is nett.her a party nor a party's officer fron1 

significant expense resulting :fro1n con1pliauce. 

(3) Quashing or l'l1odijj7i11g a !-,'11bpoena, 

(A) "f.t'her, Requin~d. On timely motion, the court for the district where 

C(nnpliilllc-R is required 1n11st quash or Inodify a subpoena that: 

(i) fails to allo,v,a reason.able time to comply; 

(ii) xeqnires a person to comply beyond lhc geographical limits 

specified in Rule 45(c); 

(Hi) requires disclosure of privileged or other protected matter, if no 

exception or waiver applies; or 

{iv) subjects a person to nndue burden. 

(B) }Vhen Permi1ted. To protect a person subject to or atTected by a 

subpoena, the court fOr the district where compliance is reqi.1ired may, on 

motion, quash or modify the subpoe11a if it requires: 

(i) disclosing a trade secret or other tonfi.dential research, 

developntent, or comn1ercial intOrn1ation; or 

(ii) disclosing. fill unretained expert's opinion or information that does 

n0t describe specific occurrences in dispute and results fr0m 1he expert's 

study that ,vas not requested by a party. 

(C) S'pecifying Conditums as an Alternatfre, In ll1c circumstnnces 

described in Rule45(<l)(3)(B), the cour! may, instead of quashing or 

1nodifying a subpoena, order appearance or production under speeified 

c0nditions lfthe serving party: 

(i) shows a substantial need for the testllnony {ff material that cannot be 

otherwise met without undue hardship; and 

(ii) ensuJcs that the subpoenaed person wlll be reasonably cQmpensated. 

(e) Duties in Responding to a Subpoena. 

(1) Produdng Documents or Electronical{v Stored l1{for11zaf/,Jn, These 

procedures apply to producing docun1ents or elcc!r-onicaily stored 

infOnnation: 

(A) [)ocuments. A person responding to a subpoena to produce documents 

must produce them as they are kept in the ordinary course of business or 

must organize and label them to coJTcspond to the categories in the demand. 

(B) Formfi1r Producing Electronical(v Stored Iqformation Not Specified. 

If a subpoena does not specify a fonn for producing electronically stored 

in:forn1ation, the persotJ responding must produce it in a fonn Dr filrms in 

,vhich it i.s ordinarily maintained or in a reasonably usable form or fbm1s, 

{C) Electronica!fy Stored Information Produced in On{y One Form. The 

person responding need not produce tllC same electronicaHy stored 

infonnatkm in more than one form. 

{D} Inaccessible Electronically Stored Information. T1:w person 

responding need not provide discovery of electronically ~to red infonuation 

from sources that the person identifies as not reasonably accessible because 

of undue btirden or cost. On n1otion to compel discovery or for a protective 

order, the p~rson responding 1nust show that the information is not 

rea'>onably accessible because i;,fundue burden or cost lfthat showing Js 

made, the c()urt may nonetheless order discovery from such sources if the 

requesting party shows good cause, considering the limitations ofRulc 

26(b)(2)(C). T11e court may specify conditions tOr the discovery, 

(2) Claiming Privilege or Protection. 

(A) lrifiwmation Withhefd. A person withholding subpoenaed information 

under a clairn that iris privileged or subject to protection as trlal~preparation 

material 1nust: 

(i) expn:ssly make the claim; and 

(ii) describe the nature of the ·withheld documents, communications, or 

tangible things in a manner that, without revealing infonnati,,n itself 

privlleged or protected, v.-1ll enable (he parties to asses~ the clai1n. 

(B} Information P1•oduced. lf infonnation produced in response to a 

subpoena is su~jcct to a clain1 of privilege or of protection as 

trial-preparation material, the person making the claim may notify any party 

that received the infumrnt:ion of the claim and the basis :for it After being 

notified, a party n1ust promptly return, sequester, or destrQy the specified 

infonnation and any copies it has; must not use or disclose tbe infonnatfon 

until the claim is resolved; rnust take re<1sonable steps to retrieve the 

infonnation if the party disclosed it beiOre being notified; and may promptly 

present tl1e infonnation under S<~al to the court for the district where 

cmnp!iance is required for a determination of the clnint The person wbQ 

produced the info min ti on must preserve the infom ation until the claim is 

resolved. 

(g) Contempt. 

The court tOr the district where compliance is required-and also, after a 

nmtion is transferred, the issuing court·-·-1nay hold in contempt a person 

who, having been ~ervet~ fails witl1out adequate excuse to obey the 

subpoena or an order related to it. 

For access to subpoena materials .. see Fed. R Civ. P. 45(a) Con1111itttx: Note {2013} 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 7 of 179
COP 015227

EXHIBIT A 

THE ST ATE OF ARIZONA TO: Terros, Inc. 

c/o Quarles & Brady 

2 North Central Ave., Suite 200 

Phoenix, Al. 85004 

DATE AND TIME OF PRODUCTION OF DOCUMENTS: November 15, 2019 at 9:00 am 

PLACE OF PRODUCTION OF DOCUMENTS: O'Connor & Dye!, P. C. 

7955 S. Priest Drive 

Ten1pe, Arizona 85284 

DOCUMENTS TO BE PRODUCED 

Photocopies of your entire file from January 1, 2012 to the present, pertaining to: 

Muhammad Abdul Muhaymin, Jr. 

See attached Authorization signed by Mussalina Muhaymin, as the 

Personal Representative of the Estate of Muhammad Abdul Muhaymin, Jr. 

Said records must include, but are not limited to, the following: 

A. All histories or initial visit patient information forms and questionnaires; 

B. All office,notes, progress notes, psychiatric notes, psychological notes; 

C. All consultation or evaluation reports and correspondence to or from doctors, 

hospitals or other health care providers, including mental health treatment; 

D. All hospital records of any type or description, including nurses' notes. 

E. All prior n1edical and mental health records; 

F. All correspondence to or from the patient or his/her relatives, employers, 

attorneys or other persons or entities; 

G. All insurance claim forms (health, automobile, workmen's compensation, life and 

disability, etc.); 

H. All prescriptions or medication charts; 

I. All notes, memoranda, writings, forms documents, reports, correspondence, 

telephone messages, excerpts from medical texts and publications and other material 

co1nprising a part of your files relating to the above-named patient; and 

J. All x-rays or other diagnostic images of same; please advise if you have any xrays available and if necessary, arrangements will be made to obtain copies. 

NOTE: This subpoena compels production of every document and record in your office 

relating to the above-named patient. The Subpoena is not limited just to records 

generated by you or to records relating just to the accident in this lawsuit. YOU ARE NOT 

AUTHORIZED TO EDIT OR OMIT ANY DOCUMENT. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 8 of 179
COP 015228

lIIPI1A COMPl.1IANT AU"fHORIZATION T() DISCLOSE HEALTII INFOITMATION 

PATIENT" NAME: M1.1ha1nn;iad :A. Muhaymin 

DOB: SSN: 8473 

I. I authorize the use of disclosure of the above-narn.ed individuaPs health information as 

described below. 

2. The follo\ving individual or organization is authorized to make the disclosure: 

3. The type and a1nount of information to be used or disclosed is a full, cotnplete copy of any 

and all protected health infbrn1atio11 fron1 January 1, 2012 through the present, including 

where applicable: hospital records, eniire nursing home/assisted living facility charts, 

transfer sheets/EMS reports, emergency .roo1n records~ triage sheets, patient history and 

physical1 nurse's notes, physicians~ orders, physicians' notes, progress notes, consultation 

reports, operative and surgical notes/reports, reside11t/patient assessments, 1ninimum date 

sets, RAP sheets~ resident/patient care plans, discharge plans, decubitus and wound repo11s, 

admission and discl1arge summal'ies/reports, photographs, social service records, dietary 

records, I&O/B&B rec.ords, weight records/vital signs, activities records and schedule~, I ' 

labol'atory reports, · pathology reports, clinical records, 

radiographic/ultras()und/photographic/other diagnostic reports and images, psychological 

reports, intensive care unit records, patient activity tiow sheets, prescription ol'ders~ 

n1edication adn1inistrative Jecords, controlled drug inventory, 

physical/occupationai/speech/respiratory therapy records, incident reports, b.ills for 

treatment, and any other records regarding said patient's physical, mental or emotional 

condition and treatn1ent rendered. 

4. I specifically consent to the disclosure of any inforn1ation co11ce1ning treatment for alcohol 

or drug abuse, treatment for psychiatric conditions, sexually transmitted diseases, HIV and 

AIDS related test results, and genetic testing. 

5. This information may be disclosed to and used by the following individual or organization: 

0 1

CONNOR & DYET, P.C. (f/k/a O'C01\TNOR & CAMPBELL, P.C.), 7955 South Priest 

Drive, 1'empe, AZ 85284 for the purpose of litigation. 

6. I understand I have the right to revoke this authorization at any time. I understand if I 

revoke this authorization I must do so in writing and present my written revocation to the 

health i11for1nation n1anagen1e11t depattnent. I u.nderstand the revocation will not apply to 

inforn1ation that has already been released in response to this authorization. I understand 

that the revocation will not apply to my insurance con1pany when the law provides my 

insurer with the right to contest a clain1 under 1ny policy. ·unless otherwise revoked~ this 

authorization will expire upon the following condition: SETTLEMEN'r. Regardless> this 

authorization will expire one (1) year fro1n the date of signature. 

7. Ilequest for :Restriction: Pursuant to 45 C.Il.F. § 164.522, I hereby request that the health. 

care provider(s) !isted above and anyone else having access to these records for the lirr1ited 

purposes of treatn1ent, payment or operations (which does not include defending a lawsuit), 

not discuss the protected health information contained in these records with any individual 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 9 of 179
COP 015229

or entity (other than O'CONNOR & CAMPBELL, P.C.) and not disclose these records to 

any individual or entity that has not been expressly authorized to receive this infonnation. 

8. I understand that authorizing the disclosure of this health information is voluntary. I can 

refuse to sign tlris authorization. I need not sign this fonn in order to assure treatment. I 

understand that I may inspect or copy the information to be used or disclosed, as provided 

in CFR !64.524. I understand !hat, pursuant to !he Hfl'ECH Act, 42 U.S.C.A. § 

l 7935(e)(l) and is impleme11ting regulations, 45 CFR 164.524(c)(4)(i), I may and am 

requesting that a co,nplete electronic copy of my medical records be provided to 

O'CONNOR & CAMPBELL, P.C., 7955 South Priest Drive, Tempe, AZ 85284. The 

HITECH Act provides that: "if requested by an individual, a covered entity must trllllBurit 

the copy of protected health infonnation directly to ancther person designated by the 

individual.'' I understand that any disclosure of information carries with it the potential for 

an unauthorized re-disclosure and the infonnation may not be protected by federal 

conlidenilality rules. If I have questions about disclosure of my health information, I can 

contuct the HIM director or privacy officer . 

• 

USS uha 'nv 

as Personal Representative o the Estate of 

Muhammad Abdul tvlubaymin, Jr. 

October 18, 2012 

Date 

) 

I 

! 

l 

' ' 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 10 of 179
COP 015230

AFFIDAVIT 

COMES NOW --~Y~a=h=a=ira~O~rt=iz~G=o~m~e=z~---' the duly authorized 

Custodian of Records for Terros, Inc. and as such have the authority to certify that 

the records attached hereto constitute a true and correct copy of the medical and 

imaging records pertaining to the treatment of Muhammad Abdul Muhaymin, Jr. 

by Terros, Inc. The attached records were prepared by the personnel of Terros, 

Inc. staff, physicians, or persons acting under the control of either, in the ordina,y 

course of business, at or near the time of treatment reported therein and making 

the record is regular practice. 

EXECUTED on this 6th day of February 2819. 

2020 

Yahaira Ortiz Gomez 

Title: -~M=ed,,.,i"'ca,,,l_,_R,.,,e=c""or.,,d.,,,s..,,,S,..p,.ec""ia..,l...,_is,._t __ 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 11 of 179
COP 015231

11il • • 

AFFIDAVIT OF CUSTODIAN OF RECORDS 

RECORD AVAILABLE 

State of Arizona Client Name: 

DOB: 

•----1 

County of Milt1 £a~ Case #: -------------

1. I am a duly authorized custodian of the records described in the attached Order, 

and I have the authority to certify the recordsJ 

2t The attacheq copy is a true and correct copy of all the records described in. the 

Subpoena/Court Order. 

3. The records were prepared by clinic personnel acting in the ordinary course of 

business at or near the time of the act, condition, or event described therein .. 

Information in the TERROS records was transmitted by, or from, a person with 

first hand ... knowledge acquired in the course of regularly conducted business I • f . act1v1ties. 

4. lnf onnation in the TERR OS records is· by or from a person · with fmt-hand 

knowledge acquired in the course of a regularly conducted business activity and is 

subject to federal laws regarding the confldentiality of client records maintained 

,in connection with alcohol and drug abuse treatment programs. See 42 U .. S.C, § 

290dd-2 and 42 C.F.R § 2.1, et seq. These regulations regulate the manner in 

which the provider may respond to Subpoenas for records relating to alcohol or 

drug abuse treatment The regulations prohibit implicit or negative disc)osures 

that may identify al~ohol or drug abuse clients .. Any inquiry that may involve 

those records must be met by a noncommittal response (42 C.FJl. § 2.13) unless 

the client has consented ( 42 C.F .. R. § 2.31) or a Court Order has been entered ( 42 

C.F .R. § 2.61 ).. The olinic, therefore, requests that the Court determi;ne the 

confidentiality of the submitted records subject to these federal requirements. If 

an Order seeking disclosure of the records is sought, the requirements for such an 

01xler, including notice and an oppo-'l""'ity for the patient be heard and the 

standard for such an order (42 C.F~R . *64) will apply. . · 

ignature of Custodian of Records 

. ~ 

Subscribed and sworn to before me this~ day of .f-.£-b~ 20 .1-? · 

Notary 

My Connnission Expires: ________ _ 

Rev.10/31/07, 5/8/07 

Fonn 21,007 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 12 of 179
COP 015232

Advance Directives Form 

PM Form 3.12.1 

THIS FORM MUST BE COMPLETED AND PROMINENTLY DISPLAYED IN THE BEHAVIORAL 

HEALTH MEDICAL RECORD 

-------------------------------------------------------------------------------------------------------------------------------------------------

Section I. Advance Directives Information Provided to Behavioral Health Recipients 

(to be checked and initialed by the consumer) 

I have been provided written information about Advance Directives 

via the Member Handbook 

I have been provided a verbal explanation about Advance Directives 

I have been provided the Advance Directive Resource sheet as a 

helpful tool in developing an advance directive. 

Section II. Advance Directives Development 

(lo be filled out by the Assigned Clinician) 

Behavioral Health Recipient has developed an Advance Directive. 

If No, stop here and let the behavioral health recipient know that assistance 

in developing an Advance Directive is available 

If an Advance Directive has been executed (developed), is it in the 

behavioral health medical record? 

If Advance Directive has been executed, but is not filed in the 

behavioral health medical record, please mark the applicable box below: 

Consumers initials Date 

Consumers initials Date 

Consumers initials Date 

Date: ------

Yes No - -

Yes No 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 13 of 179
COP 015233

_ Behavioral Health Recipient does not wish to have it filed in the behavioral health medical record 

_ Clinical Liaison/ Case Manager has asked for a copy1 but has not been provided one 

Other ----------------------------

To facilitate coordination of care: 

_Has a copy of an executed Advance Directive or refusal been sent to the Behavioral Health 

Recipient's PCP? 

Section llt Advance Directives Enactment/Execution 

Has the Advance Directive document ever been acted on? Yes ----

Date 

If Yes, have all appropriate parties been notified? 

_ Yes (specify who) _____________________ _ 

_ No (describe why not) _____________________ _ 

Revised 9/1107 MuhammadMuhaymin November 21 2016 

No 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 14 of 179
COP 015234

Maricopa RBHA 

Advance Directives Reso11rces 

About Adva11ce Directives 

Federal regulations define an advance directive as a written instruction, such as a living will or durable po\vcr of attorney for health 

care, recognized under state lasv (vihether statutory or as recognized by tl1e courts of the state), relating to the individuals \\rishes 

regarding the provision of health care when the individual is incapa6tated. 

Advance Directives for Healtl1 a11d Mental Health Care 

These are docu1nents the individual creates that appoint someone else to make health care or 1nental health care decisions in the 

event the individual bccon1es incapacitated or incapable of n1aking treatn1ent decisions. 'The instructions provided in the 

docun1ents are follo\lii'ed should an individual become unable to express his/her \\iishes. 

What to do ,vith .Advance I)irectives 

.i\dvance directives are docu1nents signed by a co1npete11t person giving direction to health care providers about treatment choices 

in certain circumstances. By creating an advance directive) the individual remains in control of health care decisions since these 

vrishes were written do,vn in advance. If the individual is no longer able to make decisions, doctors and other healtl1 care 

providers are legally obligated to follow the patients wishes outlined in the advance directive. 

l,ocal Resources for Creati11g A.dvauce Directives 

Recovery Innovations of Arizona provides a peer support specialist who teaches n1ental health care power of attorney classes. 

Please contact: 

Recovery Innovations of Arizona 

2701 N. 16th Street, Suite 316 

Phoenix, AZ 85006 

(6021636,4609 ' . 

w-eb Sites Providing Advance Directive I11fonnation 

TI1e Govenv_,r's Council on Developn1ental Disabilities; click on Legal Options Manual. 

TI1e .Arizona Secretary of State; click on i\dvru1ce Directives. 

Health Care Decisions. 

Request a Video, Advance Directive Docu1nents and Instructions or Other Materials 

I---Iealth Care Decisions, (602) 222-2229 or http:/ /WW\v.hcdecisions.org/Request Ivfate1ials.asp. 

Office of Arizona Attorney General LifC Care Planning I'viaterials and \Tidco (602) 5l12--212,0

1 or Arizona Attorney General ·reriy 

Goddard 

J\,1aricopa REH~<\ is the Regional Behavioral Health Authority for Maricopa Cotmty, hmds for services are provided through a contract ,vith Arizona 

Departt11.ent of Fiealth Services/Division of Behavioral Health and AI-ICCCS. 

Advance Direct1vrs Resocnces 9 / 1 /07 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 15 of 179
COP 015235

Non-'fitlc XIX/XXI Co-payincnt 1\sscssmcnt Attachmei1t A 

Instructions: Complete this form for all Non-Title XlX/XXl persons. Provide a copy to the person, parent or legal guardian. 

Name l\1uhammadiVluhavn1in 

I. Person's Fa1nily Ilousehold Size and Income 

A. Size of person's family household (Family consists of: Applicant parent(s) of a minor child; spouse; natural child, adoptive child and 

stepchild under 18 years of age or 19 if full time student) 

B. Gross monthly incon1e (includes the gross family income; as fa1nily is defined in A) 

C. Third Party Liability coverage: yes no 

II. Sliding Co-payment Schedule 

·-· 

Size of Fa1nily l:Iousehold by Gross Monthly Fa1nily Income : ' Co-payment based on 

i type of service provided* 

' • 

I 2 3 4 5 6 7 8 9 SIR TIMID R/1 .......................... , . ... ---"""' 

<$924 <Sl,244 <$1,565 <$1,886 <$2,206 <$2,527 <$2,849 <$3,169 <$3,490 so $0 $0 

$924- $1,244- $1,565- $1,886- $2,206- S2,527- $2,849- $3,169- $3,490- SI $2 $15 

$1,107 $1,492 $1,877 $2,262 $2,647 $3,032 $3,417 $3,804 $4,187 

$1,108- $1,493- Sl8,78- $2,263- $2,648- $3,033- $3,418- S3,805- $4,188- $3 $6 $30 

$1,292 $1,740 $2,190 $2,640 $3,088 $3,538 $3,987 $4,435 $4,885 -- """""""""'"'"" '"""""""""-· """"""""'-·""' 

$1,293- $1,741- $2,191~ $2,641- $3,089- $3,539- $3,988- $4,436- $4,886- $4 $8 $45 

$1,476 S!,989 $2,503 $3,016 $3,529 $4,043 $4,556 $5,069 $5,583 """""""""""""""""""""""""" """"' 

$1,477- $1,990- $2,504- $3,017- $3,530- $4,044- $4,557- $5,070- $5,584- $6 $10 $60 

$1,662 $2,239 $2,816 $3,394 $3,970 $4,548 $5,177 $5,703 $6,281 

$1,663- $2,240- $2,817- $3,395- $3,971- $4,549- $5,178- $5,704- $6,282- $8 $12 $75 

$1,846 $2,487 $3,129 $3,771 $4,412 $5,054 $5,696 $6,336 $6,979 

$1,847- $2,488- $3,130- $3,772- $4,413- $5,055- $5,697- $6,337- $6,980- $10 $20 $90 

$2,031 $2,735 $3,442 $4,149 $4,853 $5,559 $6,266 $6,970 $7,677 

>$2,031 >$2,735 >$3,442 >$4,149 >S4,853 >$5,559 >$6,266 >$6,970 >S7,677 Full Full Full 

* SIR is Support and Rehabilitation Services, T~I/D is Treatment, J\1edical and Day Progratn Services, R/1 is I{esidential and 

Inpatient Services. 

m. Co-payment Assess1nent for Non-Title XIX/XXI Persons 

Based on the person's family household size, gross monthly fan1ily income and third party coverage in Part I, use the Sliding 

Co-payment Schedule in Pa11 II to determine if the person is required to pay a co-payn1ent for behavior-al health services that are 

provided. Indicate belol\-·: 

Person is not required to pay a co-pay1nent. 

Person is obligated to pay a co-payment of$ ror SIR services,$ for T/M/D services and 

$ for R/1 senrices 

Person has third party coverage and is obligated to pay up to$ for S/R services,$ for T/lVJ/D 

services, and $ for R/1 services not to exceed the unreimbursed portion of the service cost. 

The co-pay1nent Vfill create an undue hardship for the person or his/her fa1nily, and thus the following is 

being recommended (e.g. reduce or waive): 

Statl Signature Title Date 

1\1

• ilgreement to pay co-pay1nent 

I ani certifying that the information providt>d in this docu1nent is true and corrt>ct to tht> best of 1ny knowlt>dge. If it has bt>en 

deterniined that I will need to pay a co-payment for the provision of behavioral health services, n1y signature belol\-' also indicates 

that 1) the co-payment and the method for calculating my co-payment has been explained to n1e and 2) I am agreeing to pay the 

co-payn1ent each tin1e services are providt>d unless other arrangen1ents have been n1ade with the provider. 

Person/Parent/1,egal Guardian Signature Date 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 16 of 179
COP 015236

Consent to Allow Electronic Communication of Protected Health Information via Email or Leaving Voice messages 

The behavioral health information collected and provided by Terros through its electronic means or a voice message to health 

care professionals1 schools, caregivers and guardian, is provided only at the consent of the client and/or guardian (if the 

recipient is a minor). 

Terres currently has a secure email system. This secure email requires user name and password to access personal information, 

but there could be a possibility, protected health information contained in such emails may be disclosed to, or intercepted by, 

unauthorized third parties. 

• Highly sensitive or personal information will not be communicated by email or left on a voice message 

• When using email or leaving a voice message, the information transmitted will be minimum information 

I hereby authorize Terros to communicate certain behavioral health information via voice message or email to me or to a third 

party for coordination of care. I understand that I have the right to revoke this authorization at any time but must do so in 

writing. I understand that the revocation will not apply to information that has already been released in response to this 

authorization. This authorization will terminate on the date services have ended with Terros. 

Should information disclosed under this consent be disclosed to others by the recipient, it is no longer considered protected 

health information covered under this consent. 

Client Signature: S1;nec By \1.;h;:rnm;:c \.1.;h;:-ymm 

Date:11/02/2016 

Parent/Guardian Signature: {SIGNATURE PAD) 

Date: 11/02/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 17 of 179
COP 015237

<EmailVJ\1Consent.ngn> 

!vluhmn1nad Muhaymin l 101 I 03099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 18 of 179
COP 015238

Member Handbook Receipt 

I have received a copy of the Maricopa RBHA Member Handbook. 

Date: 11/02/2016 

Client's Name: Muhammad Muhaymin 

DOB: 

Client/Parent or Legal Guardian: {SIGNATURE PAD} 

Recibo de Manual Para Miembro de Maricopa RBHA 

He Recibido una copia del n1anual para miembro de Maricopa RBHA. 

Fecha: 11/02/2016 

Nombre de Cliente: Muhammad Muhaymin 

Fecha de Nacimiento: 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 19 of 179
COP 015239

ADHS FORM MH-211 

Notice of Legal Rights for Persons ,vith Serious Me11tal Illness 

If you have a serious or chronic mental illness, you have legal rights under federal and state law. Some of these rights include: 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

The right to appropriate mental health services based on your individual needs; 

'J'he right to participate in all phases of your mental health treattnent. including individual service plan (ISP) meetings; 

The right to a discharge plan upon discharge from a hospital; 

The right to consent to or refuse treattnent ( except in an emergency or by court order); 

1'he right to treatment in the least restrictive setting; 

''fhe right to ffcedom ±forn unnecessary seclusion or restraint~ 

The right not to be physically, sexually, or verbally abused; 

The right to privacy (mail, visits, telephone conversations); 

The right to file an appeal or grievance \Vhen you disagree ,vit11 the se1vices you receive or yow· rights are violated; 

The right to choose a designated rcprcsentative(s) to assist you in ISP meetings and in filing grievances; 

'fhe right to a case 1nanager to work vvith you in obtaining the services you need; 

The right to a \Vritten ISP that sets forth the services you \vill receive; 

The rioht to associate with others· 

b ' 

1'he right to confidentiality of your psychiatric records; 

'Ihe right to obtain copies of your own psychiatric records (unless it would not be in your best interest to have them); 

The right to appeal a court-ordered involuntary co1nmitment and to consult \Vith an attorney and to request judicial review of 

court-ordered commitment every 60 days; 

'!'he right not to be discriminated against in employment or housing . 

If you would like information about your rights, you may request a copy of the "Your Rights in i\rizona as an Individual with 

Serious l\1ental Illness" brochure or you may also call the Arizona Department of Health Services, Office of Human Rights at 

1-800-421-2124 or at (602) 364-4574. 

ADHS/DBHS Fonn l\lH-211 (9/93) 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 20 of 179
COP 015240

Receipt of Inf on11ation 

Receipt Ackno,vledgement 

Date: 1.1 /02/2016 10:06 J,'\.l\lf 

I have received (and understand) copies of the following written inf 01mation: 

Client/ Guardian Signature 

Advanced Directives Information 

Expectation of Services 

Consumer Rights 

Notice of Privacy Practices and .t\rizona .t\ddendutn 

Notice of Confidentiality of Alcohol and Drug Abuse Information (]?orm 4.1. 7) 

Notice of Maricopa RBH.L\ Privacy Notice 

Notice of Decision and Rights to Appeal (Attachment 5.5.1) 

Notice of SI\tfl C'rrievance and ,L\ppeal Procedure ( Attachment 5. 5 .1) 

Notice of Legal Rights for Persons with Serious Mental Illness (F onn l'vffi-211) 

Release offufo1mation (Copy) (QCN) 

Release of Information (Copy) (RBHA) 

Release offuformation (Copy) (PCP) 

Release of Information (Copy) (School) 

Significant Addresses & Phone Numbers (including the ()ffice of I3ehavioral Ifealth Licensure, the 

Division of Behavioral Health Services, the Office of Hu1nan Rights, ,'\dult Protective Services, 

Child Protective Service and Maricopa R.BI-!A 

Email and Voice Consent 

Client: l\ifuha1nmad Muhayn1in DOB: 

Client ID: 099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 21 of 179
COP 015241

~ G 

>~ !'K ~•ercy mart ~opa 

.~ ln teg rated care 

MEMBER HANDBOOK RECEIPT 

I have received a copy of the Member Handbook. 

- ------------

Signature of Behavioral Health Member/Guardian 

9/22/2016 

Date 

RECIBO DE MANUAL PARA MIEMBROS 

He recibido una copra del manual para miembros. 

Firma de la persona que recibe servicios de salud mental/guardian 

Fecha 

ADHS/DBHS PoHcy Form 301.1 Last Revised: 04/08/14 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 22 of 179
COP 015242

BHAnnual - Affidavit 

Per A.A.C. R9-10-1011 Assessment and Treatment Plan 

If an assess1nent or treatment plan is conducted and docun1ented by a behavioral health technician (BH1'), a behavioral 

health professional (BHP) reviews the assessn1ent or treatn1ent plan info1mation documented by the behavioral health 

technician to ensure that the assessment or treat1nent pl:u1 information identifies the behavioral health services needed by 

the client and whether the client needs medical services. 

I attest that I have reviewed and approved the assessment or treatment plan completed by the BHT based on the above 

st:u1dard. 

Electronically signed bv: Julia Matthies BHP is/ 

Signature of Behavioral I-lea/th Professional 

Julia tv!atthies BHP 

Nan1e of Behavioral Health }'rofessional 

i\ssess1nent Date: 12/12/2016 

Date of Review: 12/13/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 23 of 179
COP 015243

Pi\.RT E: A.\NNUAL BEHAVIORAL HEALTH lTPDA 1'E AND RE\rIEW SUMMARY 

Nrune Muhammad Muhaymin Date of Birth Client CIS ID# 

. .\.ccompan)'i.n.g 'ainily l\.1en1ber/Significa11t Other (Note relatio11ship to person): see generated copy 

Date of Current Assessment/Review 12/12/2016 Date of l1rltial Assess111e11t/Last Review 12/12/2016 

Initial and or Change in Diagnosis 

Modified ])ate: 12/05/2016 10:50 l\M 

Primary Billing Diagnosis: AXIS I: 295.10 - Schizophrenia Disorganized Type 

Axis I - DSl\1 -IV DSl\1-V 

s .•. ipec11er: 

295.10 Schizophrenia Disorganized Type F20.9 Schizophrenia 

. 

305.20 (::annibus i\buse Fl2.10 Cannabis use disorder, l\1ild 

. 

. 

Axis II: 

IV71.09 I_N_o_d-iagn_o_si_s _on_A._, x_is_n_· ______ _.,_ ___ ___,f _______________ __.f __ ___, 

Axis III: 

;\.xis IV: 

30 Chronic Puln1onary Disorders 

1\xis V: 

Problen1s llith/related to housing, 

Sig1rlfi.cru1t recent losses as of09/22/2016: 

45 

Modified by: Lilliam Villalobos :NID 

:Date: 12/05/2016 

Client:: Muhammad Muhaymin 

Client ID: 099 

Date of Log: 12/12/2016 

Current Provider: 

Terros 

Medication Log 

Date of Birth: 

Active Meds 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 24 of 179
COP 015244

Inactive Meds 

Allergies 

Client Name: Muhammad Muhaymin 

*Reminder: Please copy and paste most current diagnosis and medication log from generated documents in Next Gen directly 

onto generated assessment.* 

Date, start and stop time and location of interview: 

Cm sat down with Muhammad and his step mother Annie Davis to update his assessment and ISP goals on 11/14/16, cm sat down with 

Muhammad at 2:30pm, cm did get the permission of Muhammad guardian Mussallina (sister). Mussallina is his guardian and sister, 

Annie Davis is Muhammad step mother and will be helping him attend his appointments. Cm completed Muhammad assessment at 

Maryva!e Park at 9:30am, cm ended the interview at 10:55am. 

Presenting Issues/Concerns/mental status assessment: 

Muhammad said he wanted help with everything had to offered, Muhammad presented okay he was talking and answering questions 

the best he could. Muhammad is wanting help with housing, medications management, case management. 

History of present illness (progress in recovery over last year): 

Muhammad reports his symptoms are using hand gestures, feeling like he is being followed, talking incoheant about the birds, and 

people when he was little he would think the adults are telling him to be bad or seeing little girls being bad. Muhammad step mother 

(Annie} said it could be a!! day and all night the longest it ever went for was a week. Muhammad reports never being in the hospital 

Muhammad step mother Annie report they would take him to jail instead of the hospital. Muhammad reports no current SI/HI. 

Muhammad reports no current stressor at this time. Muhammad report over the last year he has done better he has not been to jail 

and is getting more help now. 

Past Psychiatric History: 

Muhammad reports his first diagnosed was at the age of 33 after his father death. Muhammad has never been to the hospital for 

psychiatric only when he got arrested. Muhammad reports past symptoms are hand gestures, not wanting to be inside (i.e. home or 

apartment) hearing voices, Annie informed cm that Muhammad will talk with the child and see them when there is no children there. 

Annie informed reported Muhammad said the adults are the ones that make him do bad things. 

Medical History (include PCP contact info, labs ordered): 

Muhammad reports last year when he was in jail they took blood for routine blood work. Muhammad report no current health issues at 

this time. Muhammad is new to the system and has a PCP but has not seen him at this time. Muhammad reports no barriers to going to 

the PCP once he knows who he/she is. Muhammad is current going to go to Dr. Allen who can be reached at 602-797-7760 and is 

located at 3864 N. 27th Ave. 

Cultural Preferences for Treatment: 

Muhammad reports his culture and religion preference is important in his treatment planning, Monotheist Muha mad primary language 

is English preferred language is English according to guardian, an interpreter is not needed at Muhammad treatment planning or 

appointments. English is the preferred language. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 25 of 179
COP 015245

Special Assistance assessment (include contact info for Guardian/Advocate if applicable} 

Muhammad has a guardian his sister Mussallina Muhaymin who can be reached at 786 Mussallina will also be Muhammad 

payee when Muhammad receives his benefits. Muhammad was assessed for special assistance, and it was determined that he did need 

it and the form was filled out with his sister and is waiting on permeant guardianship. Therefore, temporary form was filled out. 

Muhammad is unable to understand the G&A process. Muhammad fully participated in his treatment plan along with his guardian 

Mussallina, and reported that did want his sister (Mussallina) and step mother (Annie Ruth Davis) involved in his treatment planning 

and appointments. Mussallina Muhaymin is Muhammad temporary guardianship until she is able to get permeant guardianship, 

Mussallina can be reached at 

Involvement with other agencies: 

Muhammad is not involved in another agencies at this time, Muhammad is signed up for supportive housing and is on the waiting list. 

Muhammad is not on Adult probation, not involved in DCS, DD, or another BH providers at this time. Muhammad is not involved in 

counseling services at this time. 

Family status/history: 

Muhammad reports his relationship with his family is distance, Muhammad guardian reports Muhammad has 2 cousin that is verified 

with mental illness, one has Schiophinaic and the other is unknown but Muhammad and his guardian. Muhammad reports no sexually 

/physical abuse he wants to talk about right now. Muhammad reports he feels is has affected his family relationship worse, he fells his 

family aunt got time to help him. Muhammad reports he does not want his family to deal with his mental illness. Muhammad reports 

he does have a family mentor his uncle, Muhammad feel he could benefit from community support. Muhammad reports his natural 

support is his sister Mussallina, and step mother Annie Ruth Davis. 

Educational status/history: 

Muhammad is not currently involved in any learning activities, Muhammad reports the highest grade he complete he completed was 

college where he got his Associate Degree worked toward earning a Bachelor's but need more credit. Muhammad reports 

transportation, stable, medications is a factor as well. 

Employment status/history: 

Muhammad is not currently employed at this time, Muhammad is not stable and is living in Maryvale Park, Muhammad is currently not 

taking any medications, Muhammad reports the barriers to not working is stability, medication, not eating right. 

Housing or living environment status/history: 

Muhammad currently lives in Maryvale Park with his dog, Muhammad is waiting on the MMIC housing list. Muhammad does not have 

income at this time and is not working. Muhammad is not stable on medications. Muhammad does not get SSI/ SSDI and does receives 

$19.00 in foods stamps. Muhammad lives in Maryvale Park. 

Social status/history: 

Muhammad reports his social lives involves his friends at the Park, Muhammad reports his dog helps him mentally, and his sister and 

step mother will come around to see how he is doing. Muhammad reports he stays at the park and helps his friends around there with 

food, Muhammad reports they help each other. Muhammad is homeless and stays in Maryvale Park, Muhammad report his hobbies is 

art and crafts, sewing, cooking, hand drawing, studying, wiping shoes, keeping his area clean. 

Legal status/history (include COT and Criminal Justice involvement): 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 26 of 179
COP 015246

Muhammad reports no legal or pending litigation at this time. Muhammad reports no custody concerns, Muhammad is not a sex 

offender, no probation, DCS involvement, Muhammad is not on COT/ COE at this time. Muhammad has no history of COT/COE at this 

time. 

Substance use status/history: 

Muhammad reports his does use substance; Muhammad reports his drug of choice is meth, Muhammad reports he has used alcohol 

and marijuana social, Muhammad as reports he used all types of substance and is not ready to say what he has used. Muhammad 

reports he is still researching his substance use. Muhammad reports he has used synthetic drug. Muhammad reports his longest 

sobriety was 2 months. Muhammad reports be involved in a drug treatment program, about a decade ago in and out of treatment. 

Muhammad is not currently involved in any substance abuse treatment program or counseling. Muhammad reports his barriers for not 

stopping is the privacy act and the right to bear arms (which he means bear his arms). 

Risk Assessment: 

Muhammad is not SI/HI/PAD/GD at this time, Muhammad is at risk of withdrawal or overdose/toxic use. Muhammad nutrition is not 

good due to his homelessness, Muhammad is at risk to exposure to the elements, exploitation, abuse or neglect due to his substance 

use and his current homelessness. 

Brief summary/areas of need to be addressed in ISP (what will the ISP goals be addressing?): 

Living Goal: I want own apartment/ Muhammad needs to keep in touch with cm and guardian for updates on his housing. 

Learning/Working Goal: I want to work part-time to earn money/ Muhammad will meet with RS for supportive employment 

Socia! Goal: I want attend community groups/ Muhammad will meet with RS to community support services. 

Health Goal: I want to visit with PCP yearly for routine check-up/ Muhammad meet with the PCP for intake. 

Strength's 

Muhammad has work history 

Muhammad has the support of his family 

Muhammad has the support of the clinical team 

Muhammad will attend his appointments 

Muhammad can cook and clean 

Muhammad utilize the transit system 

Muhammad has support from his dog 

Muhammad does get food stamps 

Muhammad car drive 

Muhammad has Associate's Degree 

Clinical Team Recommendations: 

Case Management: activities may include assisting, maintaining1 and monitoring covered services, finding necessary resources 

to meet basic needs, coordinating care with family and other agencies involved, outreach and follow up1 and other activities as 

needed, 

BHMP Services: Services may include ongoing medication management involving the review of effects, side effects, and 

adjustment of medications to prevent, stabilize, or ameliorate symptoms of a behavioral health condition. 

RN Services: as needed through activities that may include the measurement of vital signs, assessment and monitoring of 

physical/medical status, review of the effects and side effects of medications and administration of medications. 

Clinical Coordinator recommends she attend all MD and RN appointments, take all medications as prescribed, counseling 

referral as needed, engage with RS and FM to increase daily meaningful activity and enhance natural supports, Ensure follow up 

with PCP and other medical specialists as indicated. CC recommends individual counseling. 

TRANSPORTATION: CM or ACT specialist will support by assisting in coordinating, arranging, or providing clinically necessary 

transportation for medically necessary behavioral health services. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 27 of 179
COP 015247

Rehab Specialist: Rehab Specialist services may include assessment of level of assistance he/she requires to create, plan, and 

successfully work towards accomplishing his/her employment/learning and social engagement goals. 

Peer/Family Mentor: Services may include group teaching independent living, social, and communications skills to persons 

and/or their families in order to maximize the person's ability to live and participate in the community and function 

independently. 

Electronically signed by Kimberly Bryant BHT Is/ 

Kilnberly Bryant BlfT - Provider 

Behavioral Health Professional Reviewer Name (print)/ Signature 

Terros 

Agency 

1211212016 

Date 

Date 

REMINDER: All demographic data reported to ADHS!DBHS rnust be revlev,1ed during annual update. Based on this revie,v: 

At a n1initn1m1 the following dernographic/clinical data fields rnust be reported to A.DHS/DBHS regardless of whether they have changed since the 

last data subrriittal: Axis t II and V and GAF/CGAS, behavioral health category, ernployrnent and educational status, priniary residence, nUinber of 

arrests since the last data update and prin1ary and secondary substance use; and/or 

All other demographic infonnation that has changed (e.g., other agency involve1nent, income for non-Title XIX/XXI eligibles). 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 28 of 179
COP 015248

I 

Nan1e: 

Date of Birth: 

Age: 

Social Securitv #: 

• 

Rac.e/Ethnicity: 

Preferred Language: 

Address: 

Phone Nu,nbcr: 

E-n1ail address: 

AHCCCS Coverage; 

ASSESSMENT FOR LEVEL OF C..:-\RE 

Mubainn1ad Muhay1nin 

43 

~ !\1ale D Fem ale 

Black 

English 

IIOMELESS (1na.iling) PI·H)ENIX, A.Z 85041 

--0786 

·i--:ami:: .\:Juh,:mmm! Niahaymin 

Dale ofHit1h: 

I 

------------·-------------------........................................... _ 

~ Yes O No, Jjyes Al1CCCS ID#: -0335 andAHCC'.CS lfealt.h Plan: MC ------------------·-........... -......................................................................... -..... _______ _ 

Insurance Coverage: None 

------------------------------.... -........................................ .. 

En1ergcncy Contact: Name: Mussallina Muhayinin- sister and guardian ------'--------"'----------------... -.......... - Address: Unk11own 

Phone Number: ---0786 

Prilnary Care Physician: Name: None 

---------------------------- Address: NIA 

Phone Nurnb~r: N/1\ 

Place of Evaluation: CPR Tempe 

Date of Evaluation: 9/22/2016 

Referral Source: f an1ily Jnember if other, spec(fy who: Mussatlina ~Auhayn1in 

E valuator!Credenti als: Tmnara Lan1011tagne, LAS1\C Phone Number: ( 480)804-0326 

MEDICAL HIS'fORY: 

M.cdical Conditions 

Condition No/Yes Additional Information (onset, treatment, etc.} 

Diabetes rgj 'No D Yes 

~ No [J Y cs, If yes, what: 

,_ .... .......................................... - Heart Disease {High ' 

blood . nressure. heart . > 

attac~s, etc.) .. 

Strokes f8I No D Yes < 

... 0 ... No ~ Yes I/yes, whar: asthma ! """""""""""""""""""""""""-"" 

Lung Disease (Asthn1a, 

COPD, E1npbyse1na, ' etc.) ' 

Seizures IS] No D Yes > 

Cancer ~ No O Yes ![Y..~.~i .... :..~:..!.~.C!J.JY.P.~.:: .......................................... ' "',, -· "',, 

LiveriKidnev Disease !XI No I I Yes 

Name: Muhaymin, Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 29 of 179
COP 015249

-- -- ·------------------------------------------------

Medical Conditions 

Nmn bcr of pregnancies i ~-tale 

and number of live births? ! -------------------------------------------------.1 

Difficulties because of I '

1

No. H 

n1edkal issue~? ! 

MENTAL HEALTH HIS'"fORY: 

1\<lental Health Treahncnt 

... 1⁄4"I~ype .................................................................................................................................................................................... -...... -~." ....... ..,..,,.v.-.... ~ l,. \\' lier e W lien \V hy /Diagn~o~-s~i~s~~-------1 

OutpaHcnt - rvredication Management and Counseling I PreSM1 determined in BIIR never engaged in 

I 20 l O ! .services; tva.s never opened I l 

------------------~~-..;,..I ~-------i- I with a clinic. 

I I ~-----------------------------------------------------------1-------------------------------- ---------------------------------- -------------------------------·-----

~--w.,,,.,. ............. _ ............. .......,,._.,.,_,_.,,......,.,_._. __ ............. , ............. ...,,._.,._._.__... __ ...................... ~...,,._.,._._.__... __ ...............................................,________ t--""""" ......... ,,.,.,,..,.,, ............ ~,.,,,,....,........., . ......_i-,.,.-,-•~~-~---------------•C 

I ------------------~ .., .. ,....,, __ ,, .......................... -,,.., .. ,.,.,,,,,., .. ,.,.,,,mUtnl""""""''"""'"''''~• _y,....,,_•.~~••l'-"N..V"""Y'"'"' ...... "NM¥-.,.,_.1'101+j"Ul"t''•~• ............. --------------

I ---- , . , I 1 

I ! I 1 

I i 

Other: BHR was unable to provide his mental health history. He can1e into the office then .in1mediately feU asleep as soon as 

lhe eva[uation began. He ,vould n1ake up [ntennittently but never spoke. lie only tnade noi5,es and gestured fro1n time to 

tirne. 

MRDICATIONS: 

. ., Cu rrc n_t 1'1 ed i cations .(psych la tJ•ic and nte di ca_lj ,mmm.• •mmm•-•--mmm•--·--•--m•--mmmmm•--mmmmwmm,.,mmmmwm•--•--mmm•----mmmmmmmwmm,.,mmmmm,mmm __ , __ m __ m,m--mm•-•m--m-m 

i\1cdication Dosaec A.dd~!_ionaI I~1 formation (i.e. reason f(!,,!:.. .. B..~ ... F!J!.~1..B.~Y~~q ... f? .. r.. ... q_(!J~.~-~-~£!.!.(:£1N---

None 1 NIA NIA 

I 

-~----~~-,....,.__-~----------+----••...........,...,__, .. ~-••....,........,,,....,,,,.,.,.,,....,..,,.,.,.,,,mmm,,,.,.,.,,....,..,.,,.,.,,,mmm,,,.,.,.,,....,..,.,,.,.,,,mmm,,,.,.,.,,....,..,.,,.,.,,,mmm,,,.,.,.,,.,,, .. .,,.,,,,.,..,,.,""''"''""''''""""''""''"""''"''""''''~.•.-.-.,.w,•N 

! ! l------------~~---~-------1------------------------------------------------------------------------------------------------------------

Side effects?;'\[/ A .,.,.,___...,..-,.....,,,.., ..... ..+,,...,..,,.,,,.,,,1.,,,,,.,..,,,.,.,,.,.-............ .........._. ............. ....._..........._..........._.....,_..........._..........,...........,..........._.............,....._..........,............_.............., •• u••••••U••U•• ................ u••••••U••U•• ................ u••••••u••U•• ................ u••••••u••U•• ................ u••••••u••U .... • .............. u••••••u••U•u.u••••--------I 

Efficacy of current and past rnedkations? BHR's guardian \vas unable to recall past medications, 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 30 of 179
COP 015250

~mr::t: J\·1ulrnrnmHd M1Jlrnym tn 

Date ..:1 r Birth: 

-•,~l:!!!.~,~~~ s . ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• •--••-•••-««••·•vNHHN~••••-«HNH•vu.vH•~••••-«HNH•vuHHH~••••-«HNH-NHHH,-••••-«••-HHH,-••••-«~•••••••••-•••----,.-wNNWHw-w=-

Desc ri ptio n (including onsett precipitating events, duratinn1 frequencyF triggerst and specific exrunples like quufej): 

The BHR 41 year old! single, Rlack male \Vho was seen at CPR Tempe ,vith his guardian/siste-r} !\1ussaUinr:t iv1uhayn1fn1 for a 

Pre.SMI evaluation. He is T 19 with; Jv1C, hon1eless and not e1nployed, As stated above, the Brfil fen asleep as soon as the. 

evaluation bt=gan. He would inake up intennittently but never spoke. I~Te only made noises and gestured fro1n tiine to thne. 

AU of the infonnation gathered below was fron1 the sister/guardian~ 

Presenting Concern: f'\Vell, l applied for guardianship and l have te1np guardianship and I ,vant to establish services for hint 

and rene"'' rny guardiansbip.f1 

'fhe BHR1s sister reported he ,vas diagnosed with Schizophrenia and Bipolar as well as an addiction in the past, His 

syn1pto1ns include: 

Depression: 1~1 don't know. l sec n1orc of the Schizophrenia stuff/' his sister ans,vcrcd. 

N1ania: tlfo gets vvhcrc he is real hyper, scrcmning at the top of his lungs and making up s.ongs. ir BHR's sister \Vas unable tn 

provide n1ore detai1s. 

Psychosis: uu·rn} he is just saying really crazy things like asking if he can choke rne and he used to teach 1narital arts at the 

con1rntu11ty ,college..'L He syinptoms .started 1 think in 2006 \.vhen our father passed because he and 111y father were real close. 

They t't)Ok care of hin1 in the fan1ily. 1r BHR1s sister endorsed he has AVH as ,Nell as delusional thinking "our conversations 

don·t 1nake sense". At the thne of assessmtnl~ the BHR appeared unable to speak and only rnade hand gesturesT 

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------~ 

Difficulties because of symptoms? 11Homelessness and the addiction canle after and he has been arrested a lot. He ,vas 

.stab bed recently. i, 

H:o\1/ wiit yon knn\.V if thjngs are. bener/hnproving? ,tHe's not like this.ti 

\Vhat type of assistance do you fed you need? •iHe needs aU the help he can get.H 

--·---------------------------------•T"------·-------------.......................-·~~--.----------.----.... ,,..-----.-----...--... ----~-----

I-Hstory of su?cide 

:attcrnpts? 

Current ideatcon} intent, I C8J No O Yes Jjyes, explain: 

_ _El ans~ or_ access_ to_ means? __ J-----·----·--------··,~~-----~-----------------------___________ _ :h.1ost recent suicidal ! ~, I don't kno\¥. r, 

ideation? Was there intent I 

or a plan? ! 

liistory of banning I O No O Yes !fycs, explain,' t, t don't kno,v. u 

... 5'..~~~.~E~.7 _ . . . . . J 

Current ideation; intent, I r;J No D Yes !fye:s. eJ·p!ain: 

p!ansr or access to means? ! 

Most recent hon1 icidai I irl don't kno\-v, '' 

ideation? \Vas there intent ! 

or a nlan? ! 

Hi.i:;tory ofsdf-injuriou~ ft'.8J~No y'es·-{fyes; explain: 

behavior? l I -------------------------------------------------------------------- was Duty to Warn I ~ N~ □ Yes {f yes, explain: 

.... conlJJl.eted? ............... -..... i .......... ·--------~~-------------------

SUBS1"ANCE ~~USE H1S1'0l{Y: ~~--------------------- Substance Abuse 

--------------,~------.....---------------------•~w,--,w,~-.~.-,w,~-.~-wv-w,,,-a,__e,-~~---

.~!~e --~.,~-----~--~---------------,,,.--~ ~-~s-~ __ t; sc Last Use ._ .. _ ........... lHstnr~/ Pattern o!,' use (tyJ!!~ ... ?rno1111t 1 and freguencyJ. ........ 

Denied ! l - ................................................................................... t ...................................... ~ ............... . 

i l 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 31 of 179
COP 015251

Nnmc ~-h1b.armnad JvI uhaymin 

Substance A.buse 

Tv e First Use --,--------~--------~----~-----"'"'"'"'""""'"'"'"'""""'" 

Last Use Histor,1

/ PaUen1 of use (t • 1c, amount, and fre.9:u!!.!_IC_ ) 

-- --------------------------------------·-----t--~----,:----------t--------------------~-----l 

l 

------t-----------------------------

-~---~--------------, ................ ~·t--------~1 -· ·~-- --..... ---ii----- ----~ 

l -~~",.--,----·----.-..+-----~ .................................................................................... ~ .... ____ _ 

Othe.r: □ l Hfs s1 ster was unsure but kno\\'S he uses son1cthing. ,r-ie asked 1ne for ice before. I <lon 't even kn O\V what that is.;, 

.~P~~JL_Of choice? -----------!-'~--~i? __ o __ ):_e~ __ ff1-?S, what· .. . --------------'I 

Longest period of ! NIA 

sobriety? How did they I 

function durin s_obriety? -- 1-{istory of substunce D No D Yes, {(yes, explain· t,.lnknovvn 

abuse treat1nent? 

in1pacted functioning? 

Additiona] I 11 format ion: IN/A 

LEGAL I-fIS1"0l{Y: ~--·· -·· -----------------------------------------------, ~!:e~,~al _____ _ 

History of arrests'? l D No 0 ,/es ({yes; explain: BHR has been charged \vith nn1Hiple things including 

-------------;!_' ....... ' os_s~_ssi~n, trespassing, t~ai~~r~_!O aEe~ars and stuff !ike that''. ===~w-=~w-=• 

Sentences? ! His sister re orted she knO\VS he has served at least 2 years and 'jin and out over the vears~'. 

Additional Inforn1ation: No current )endiu- le 0 dl issw:.s. 

-- Education 

I . - --

Highest ]eve! of Graduated high school and con1pleted some coHcge. ••' 

Education? I ~......,.,,.,., ....... _ ~ No[ .. ] -......., ..... ....., •• .....,.,_~--=.-.=··~NN.·.VN.·.-.·~·•.-.w.~•-=.-.=··=•·VN,•h¥llJ'.•.-.w.~•-==··=•NN,•h¥llJ'.•.-.w.~•-WNllNll.•ll,'N.•NN,•h¥llJ'.~~-·NN.VJ.0N.•.v,-.ww ...... w ...... -,.,,.,.,_.~.-

Spcc.ial Education? l Yes /lyes. explain: 

l .,.,.,,. .. ,..,u.,•••••uo.•u••••••H••uu••••u••u••••••H••uu••••u••u••••••H••uu••••u••••Hu•L••••••••u••••••••Hu•L••••••••u•••••••--

Additional Information: N//\ 1 

En1piorment 

Currently ·E1np1~ye(l? .. "' '' r lJ")·~·es'l~""K o"iji.~~s:· d~-~-~~·;~lbe the job .. /typ,:• ... qf work .... PT.or .. FT, ... etc,), .... !f no .. describe ... 1he .. lastjob: ............. 

BH.R \Vas last en1p]oycd in 2006 uhe and n1y father o,vned a 1nartial arts sc-hoor. 

INTERPERSONAL FUNCTIO~ING: I ~~~~~--~· 

~~:!~"~ .. !!}.~.~?.~~ .......................................................... ,_ _ Raised by? --~--~-~-w-•--~-~-~,.~,w. L~1 ~1.Y dad and any 111 other died_ \V hen _v,;e v.;ere teen.age.rs.)' -~---~-~---~-~---~-~---~-~---~-~-~--~~-~--~~-~--~~-~--~--w _ 

Siblings? 2 sisters. 

Description of Childhood: BHR \~ias born and raised in \le\v York and can1e to AZ at age 14, 

History of Abuse? 0Nok8J Yes If yes, describe:- On the streets BHR has been abusedl stabbed~ beat up) etc, 

Developmenta! Milestones 1 ~ tvtet D Not Met~ explain: 

(walk> t~!kt an~ot!}' t.r~}~ -- C,)nl~)lic.arions at birth? l Nil\ 

Farnily history of n-lcntaI j No kno\-vn me,ntai health; No suiddes; asthn1a~ HTN and prostate cancer run h1 fmnily~Father hx 

illness, suicjdes} rned ical ! of crack cocaine 

issues, and substance l abuse? l 

I 

' Relationship Status: j ~ Single D Cotnrnitted Relationship D !Vlarried D Separated l~J Divorced [_J \Vidowed I 

I l Relationshir, Hisrorv: ·t,o current kno\vn current relationship. . .,J ,_ . .....,...,,, .. ,, .... ~....,.,,..., .... ,,.,,., ... , ..~... . . ....,.,,,,."NNN~·-=·-. r!'..v.•.w.-,.,.,.w--.,.•.w,,,-, ............. ...,...,,.._._=•·w.-.•.w,,,,,.•NN,.,W,,,, ..... ~..,,.,,....~·~•-w.-.•.YN.",.•NN,.,V.,,,.,... •• ~~•.v.,.v,-.-.-.-,. ••• ""· ... ' .... . "· .,,,..,."NN.w.,,v.•.w,,.., •• NN.V.'."N.·.YN.",."NN.w.,, ..... .....,.,_Wll..,.h"NN.·llo'N.·.'."N.•h-,.,.....•.-.w.wN..,.h"NN.·=·•'Hh•.w=.•.-.w.wN.-,,.w,, ..... 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 32 of 179
COP 015252

Nnmi::: Mulu.unmc1d i\1nlrnymin 

Datt of Bi11}1; 

Socia J History 

Children: 2 children a )es 23 and 1 O; no contact 

GENERAL Fl;NCTJONING: r'"~"•''••u..-.,...•.YH...._ • .,...,,......,..._..,,...,,. • .....,... .... -,.,,.... •• ..,,.,..~•,.-.,.,.....,.,.,.._•..-....,.•..-.,.,.,.-.,.,,,..~.•.-.w.. ... •.,.._,..-.-.,..._..,,..,.,...,...,,..._..,....,,,. •• ..,,,,..._ • .,....,..,........, • .......,_~ • ..-.,n,.....,. •• ....,.,,_........-........,,_._..,,_._._.........., • .,.....,,_._..,,_._.._ • .,..., • ......,,_._..,,_._._.........., • .,.....,,_._..,,_._.._ • .,..., • ......,,_._..,,_._._..........,.,......,,_._..,,_._.._ • .,..., • ......,,_._..,,.._.._..........,.,....,.,,_._..,,.._..._......., • ....,.,,_._..,,.._...,........., • ....,.,,_._..,,.._...,......., • ....,.,,_._..,,.._...,........., • ....,.,,_._..,,.._...,........, • ..-.,.,..._~..,........,.~-~..,........, • ..-.,.,..._~..,........,.~-~..,........, • ..-.,.,..._~..,........,.~-~..,........,.~.•~~•~.•~~•~.•~~•~.......,.,......,,_._..,,,_..,.~~ 

Living Situation 

Li vjng A.rrange1nents Horneless for tlle last 6+ years. 

Source of Finances · None. 

_ Method_ a f Tr ans po rt at i on __ J __ '

1 \Valk . 1

; -------------------------------------------------------------------------------------------------------------------------------------------------------------------

- - _'1-..,..,,.. .... .....,_,...,._-'+ .. 

. ;;~1;:;;e1~;:~t•x_ U~in~ H , .... ,,,,,, .... ~ ........... ,., ............. ,_..............+,,.+r+.+....-..,.,.,,,, """'''"'"'"'''"""'' 

Denied eroblems Difficulty reeoned (eiease exelain) 

• Bathing l ~ D 1

'He looks clean \vhen \Ve. rneet up. 11 

...... 

~Grornning1l-1ygie11e _[?.<} LJ B HR _did appear clean, neat and it nic\v clothing. 

• Preparing food ~ _ ! D "He has lost a lot of weighr since J seen him since August. He had a 

~-.... -- .... _ ---·····-.. -... -... - ........... ~ .. ~tan}£ card, but l don't_ know _what IE:££~ it:'.'._~H-1⁄2WNH~•~N-

• 1\1obHitv i , ~-,-,-·~-,w.·~w.·•- • •-·~~----,·-~~.w~,w,_,_,_,·-~~.w.· 10 •~sw,_,_,_,·-~~.w~,w,_,_,_,._,~~-~. ,., 0.w,.,w,N.·~WNN.~·-•-'w,N.·~---~·-~,w,N.·~----,·-~~-•-•·~----,·-~~-•-••~--.--.·-~~-•-••~~--.--.·-~~w~,w,_,_,_,w,~~-w~,w,_,_,_,w,~~-w~,w,_, 

• Housework l Homeless 

• Shoppinf; □ 0 Unkno\vn It Managine: 1noney L .. J [] \ro income-. 

• Taking n1cdication l □ 13'.l 11He onlv stays on 1neds unti 1 he is incarcerated. 11 

L __________ __.__ ___ ..:t.::::...____.__, • 

Typical day 

\Vhen asked to describe_ their typical day they replied~ ·~BHR n1ade noi~cs and n1otioned i~_k __ e_h __ c_i_s __ "'vv_a_I_k_in~g~· /_~------~ 

BEIIA ''IORAIJ OBSERVATIONS: 

General Appenrance 

- --

Dem ea.nor /Interaction 

.Ivlood (as reported by I uBH R made a gesture he ,vas hungry:r f 

!-

I 

the individual) 

□ E{iii~·);mic~ LJ Dysph~ri1⁄2~NN N~up"h~'~·~□ lr0ritabie A~;;ious~tJ Angry O Euphoric -~?l~Fiatw~www , ....... ..,.,. .... -.~ .... 

Affect (as observed by l 

The evaluator) l D C.onstricted D Labiic } 

f 

! Eve Contact f [J Appropriate Cg] ~-1inin1al D Poor O .Adequate D Cons_~nt I f 

' t I 

l Cooperation f 

f 0 Good =:] __ Resista11t ~_Hostile _Defensive LJ Evasive i:8J Apathetic l 

: 1\dd1tional information: __ ...,.. _____ ..,._ ________________ ...,.. f 

f NIA I, ,,,.. ....... ...,,....-.-.~-,- ·,t,N•·~~~.-.w.,.•~=•·..w.•N,WV.•.......,._w,·=,..,.,..,,._,·.~=•.-.w.·NNN.·.....,,._~ •• .,.,..,.,,,..,.,..,,._, •• ~HN.•.-.w-.·NNN.•....,,._w,·=.-.-,.,,.-,.. 

Sp~cch D 

Articulation i O Goal-Dirc.ctcd [] Unintc[Hgiblc l.. ..... ! \1umbled D S]urred [] S~Y.ttereg-'=c.c,__C_k_a_r ____ _ 

Tone t D Norn1a! D Soft D Loud 

Rate ! LJ Normf~i C Slow D Verbose D Pressured - - - Res onse Latent t t'W"! Within Nornut! Lirnits f""'"f"'iS~f~~y~d 'D's11~)1:t~~e,f"'""" .. "'""' .... "'""' ............................................................................ ... _, .. ,-.. ~, p •-HHHH-H-'H-~-~~-~-.... :Y ............................. 1 ,~--·--~·~-----•-_;;:=-_._--,:. ........... -==:..._..~~~~----~-------------, 

Additional Information; ! BHR d~d not speak. ---~~-~-----··-~ - ----~--------------------------------

f i\'1 otor ,\ctivitv 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 33 of 179
COP 015253

l 

L --

Name; ~t·f uhar.inrnd \:hthiiy.min 

Date: ~if .Birth 

,----------------------------------------~--~-~---~--~-~--~-~----~--~--- J\llotor Activity 

__ Qi3-i!__________ · --f-Qs] Norn1al D Staggerin r D Shuffling O Slo,v D A wkvl"ard LJ Use of Cane. 

Posture . I r2:J_ t,.;onna! D Relaxed _O_ Ri_g_id D Tense D Slouched O Erect ~~~~;~~=u~r~ei!o~-~1~ill:t~::~~~-DJEko9~~m::~~i~o~~;~,~Jcilli1E~~-ac!i_v_1;_Q=_it_at_~e_d __ -l 

Additional Information: t N/ A - --------~-----------------------------·-· -··-·-••1-•-·· ---··-· "'"'""""'"'"'"'""""'' 

Perception (as observed 

by !he evaluatnr ~-- i.e. 

responding lo unseen 

otherJ,) 

! t-1 Unremarkable D Auditory HaHucinat.tons U Visual HaHucinations D Tactile Hallucinations 

! D {)Jfactor{ Hallucinations D Gustatory Hallucinations f ~ 

f 

f 

l 

f 

f 

l 

___ l~~)_p~l~~--~-~~trol { 0 Good O Partial O Limited O Poor D None 

Insight_~l□ _Good D Partial D Lilnited D Poor D None 

~---~-

Additional lnforrriation: f BHR did not sneak. - -••= .... L ..... ~ ............................................... c ___ , ______ ~------------------~----- -.--..... ....,,,..,... ______ ...., 

-In te.JHgen Ce ---------------------- --------------------------·-·---------------------------------------· ------· --------------- -------· -----. ------- --- ' -

Esthnated inteHigence I I Average[] Below Average D Above Average D Borderline 'Intellectual Functioning ---

D InreUectuai disability [8] lTnable to detcrn1ine 

Addition.al [nfonnation: BHR did not speak; Miv1SE was unable to be con10Jeted due to the condition of the B1-{R. 

1\1EN·T.AL STATUS: 

Mini Mental Status E-xant !---•~~~~~---~-- -~ -----~----~-...................................................... -..... ..__,._,.,...~"""" -w 

Category i\il etlSU rem en t Results 

Orienta1ion Asked,abou,U1~~on~ place) tinie, and situation. ·-· ·- Attention Asked to cornplete Serial 7~s (counting 

backv,rards fron1 100 in incre1nents of 7) and 

the '\.vorld~' task (spelting the ~..vord ~'\vorldH 

forwards and back\vard.s. ~ ._._. 

In1mcdiate R.ecaH .Asked to repeat three \vords: '~Robin, Blue, and 

St Louis," ---

Nan_}ing . A sk~~,.to identify a_ ~en and_ ,v a tch.m.•m-~m,~m-•--~~m-•m-~m,~m.-. ......-......-,-.-.-.-,-.--.,-,.,...,..,.,..._.,_...,..,,..-.... -r.....,..,..,..,-• .._-.-,-.--.-,.....,.....,._., • ...,..,..-.... -r.....,..,-,-,-• .._-.-,-.--.-,.....,.....,,._., • ...,..,..-.... --r.....,..,-,-,-• .._-.-,-.--.-,-....-,-.--.-_..,..,..,. • .._...,.. • .._...,.. .... -,-..._-_.,_w .... ....,._-....,.,,-,. • .._.,._.._...,.. .... -,-..._-_.,_..,.._.._.._....,._-....,.,,-,. • .._.,. • .._.,.. .... 

Repetition Asked to repeat the phrase: "No Ifs; ands~ or 

buts.'' 

Fol1owing Instructions Asked tc, take a pjece of paper in their right 

hand~ fold it in half~ and set it on the table. -~-

Reading Vias sho\:vn a picc-e of paper that read; '~close 

your eyes, Band asked to read it and do what it 

says. --- - --- -

\Vrit1ng lnstructed to write a sentence of their choosing. They "vrote: ~~ '' " -

Construction Asked to draw a dock \Vith the hands pointing 

to 11: TO mn. l'-._._... •• ._._......,._._._..,,......_ ......... + .. uH••u ............ H ... u ........... 

Ddayed Recall Asked to recall the above words after a five 

minute delay. ..--....-----------------------------------------------------------------------------

--------~-~.-----.. ---. .......... ..,,_ .. ~. ~_..,...,...,..,..,.,..., .......... _,.,..,.....,..-v-,-,. ............ -,.,..,.. .... ..-vv-,. ............ -,.,..,.. .... ..-vv-,-.., ....... ., __ ,.,..,.....,..-v-,-,-..,...,.,-.~ ... -++-+',....., 

~-Higher Executive Funetionin~ .... ....,...,.,, ... .,,,,, .. , .... ,, . .,. .......... ""''"'"'"'""'""'"""'"'''"""''"""".......,.,.... . .....,.,.,.. ......,.... ......,.,.,...,...,.,.,........,.,.,.....,...,.... __ ...,,,,.,._.,...,.,.,........,.,.,.....,...,.... __ ...,,,,.,...,.....,.,..~~---· ~-~._ ......................................................................................... " .. - - - ---- ·-

Category Ivf easu rem en t ! Ilesults 

Current events Asked to the last three presidents of the i They responded: H n nanlc- I 

I . I 

United States. 

I 

I 

I 

Judgrnt!nt Asked \Vhat t11ez· \1/0111d 

-------------------------t---------------------------------------

H ~'t do if th~• encountered I They stated" Hand ............... I I, .. ;I I I ,,,,.,.,.. .. ,~ ,-,..,..•~.•.-.,.-.-~~• • ....,....~.•,•N.w~•.VN.•N.v.-.•,.......,._w,•.....-....,..,.,._•,VM.u,:..u,.......-.• • ........-~ •• .......,.J. .. ..,...,_, •• NN.w.•.-.•,......,.~•--•• I I I I I I I I I I I I I I I I I I I ' ' I I ' ' 111 , . , ........ ~.--............... 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 34 of 179
COP 015254

-- ·--·- ··------------~-----------------------------------------

lfi0 her Executive Fnnctioniu 

Problem solving .... 

Abstract thinking 

.Additional information 

J\'leasurenient 

a burning house in their neighborhood and a 

stamped~ sealed~ and addressed envelope on the 

street. 

.,;\sked to identify the. similarity bet,veen an 

a le and a banana and a car and a boaL .... --~---- ..... ---- -. 

Asked the tneaning of the foHo\ving proverbs: 

'"Don,t cry over spilled 1nHkn and "Ron1c 

w·asn l t built in a da .t1 

C1inical records obtained; D Yes ~ N·o If no~ explain: 

DaH; 0 r 8.irth: 

1 Results 

respectively 

They repI ied: ~, 

- - -- - - " "------------~----! 

Thev said: " ,; and H ,, 

rcspccti vc ly. 

Pend options: -3-day □ 20 day pend -E-E-P-lf~3-d_a_y"-e-,x-pl-a-in-: P-r-c-SM_l _______________ _ ___________ ,,,,m,1UIIU" .. ,_..,.,,,mmm1, .. , ....................... --..,._ ... .,., ... ,., .. ,.,. .. ,u,unuuo"o"n""'"'""""'"'""""'""'"'"'-''N1YN.•.W.,.WNN.-."<W.".•.-HY.••YN.•-•-....••NN,.,.,,,,...,,_.,.,,.,,,_.NN.•N.-,'•hn-.......NNN.•.-HY.•NN.•N.....-.••-•--•• ......... "'""''""''"""''"''"'"'''""""''""''"""''"''""'"'"'"""'''"'"'"'''"""'"'"'"'"""'''"'"'"'''"""'"'"'"'"'""''" 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 35 of 179
COP 015255

. ---------------------------------------------------~ 

N mnc: l'\h 1hmrnr.~d tAuhavm.in 

Dat,· Gf L3irth: 

SlJMlVIARY: 

--------------- --------

Clinica I .summary ·-•-.--,-------~--···~· .. ··"·-~-·-------·-·-N•-··-··•w••vHHHH-VVVV-•·•w•·•vHHHH-VVVV~•·•w•·•vHHHH-VVVV~•·•w•·•vHHHH~-HHH-Y••··•·v•••-HHH-VY• .. ·············~, 

The BHR 43 year old, srngle, Black male who was seen at CPR Tcn,pc with his guardian/sister, l'vfussallina f'v1uhaymin, for 

a PrcSi\lH evaluation. He is Tl 9 with, :tvlC, hornelcss and not employed. As stated above, the BHR fell asleep as soon as the 

eva)uation began. He wou[d niake up intc-nnittcntly but never .spoke. He on·ly 1nade noises and gestured fron1 time to tilne. 

All of the information gathered he1ow \Vas from the sister/guardian. BHR•s sister reported he is prin1arily psychotic, 

delusional and having A VlI and is una\vare of rnood syrnptmns, anxiety or \\'hat substances he n1ay use. Given what is 

kno\vn_, the BH.R app_pars to _rr1:eet_ criteria for F20.9 Schizo hrenia. ---------~-------------~-------------' 

DJA(;NQSTIC IMPRESSION: .----------·- --- ----------------------------~~~~-----------

F20.9 Schizophrenia 

Z59.0 Hon1ekssness 

ASAM SUJ\tilvlARY: ... 

Dhnensions 

Risk leve-1 

(O)No risk (Lo,;v) 

(1 )Mild (Low) 

(2) Moderate (iv1edhun) 

(3 )Significant {f'v1cdiun1) 

□ Con1pleted 

I I- I nmxk.alio:1 

~ Not applicable, explain: .Hx unknown. 

····":i~··"ii;;·~-;'i'f~;·;;j"·'""···"7·"";i':·"p~;adities s-·· ,.,.,..,..._,,,,.,,.....,,.,, ........ , .... 

2- Biomed ! 5- Relapse 6- Recovery environment .. _.. ..... •••~•"""'-"'-H•"""""" 

........ 

(4) Severe {Hi_gh) '-'•"-'-'•·.,....--~~,,_._-.. • ......,.v....,..,_~..-.-•. ~v..••_._. •.• -....__-... ..,,_-,......,._.,. -~ • ..,.,..,u_-....__ •• ....,_ . .,~..,-~..-.-..-."-'-·..-..-.-..-...... .,.,.,.,., L .-.-~._,.......,_-,.._._._ ••• _._._.~..__,.,_.,._.,., • .,.,.,._.,., .. .,.,.,.,.,._ ._ .-.. •• "-'-• ....._._,_-,...__ •• _._. •• .,~..,-~_,_-,_ •• "-'-• ....._. ._..__._._._._._._......,._ . ...._._ • ...._..,_._.,_..,_._._._..__._._._._._._.._._,._ . ...._._....._..,_._.,_..,_ ,.___.__.,.._._._._._.._._,._ . ...._._....._..,_._.,_..,_._._._..__.,.._._._._._.._._,._ . ...._._....._..,_._.,_..,_ .._..__.,.._._._._._.._._,.__ . ...._._....._.._.._.,_..,_.,_._._..__.,.._._._._._.._._._ . ...,._._..i_._.._._._._._ • ...._~..-..~.._._._.~.-..-~v-~..-.-..-."-'-•..-..-.-..-_-,...__-,..~.-..-~v-~..-.-.. .• "-'-. ., ..... .,_-....__ •• ~.-..-~~ 

LASAC II .Evaluator 9/22/2016 

Credenti.aJs1l>osition Date 

Supervisor's N an1e (print)/ Signature Crcd en ti a!s/Pos iti on Date 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 36 of 179
COP 015256

N.am~~; iVitdrnrnmmJ i'~'J ulwymin 

ADIIS/DBllS POLICY i\ND PROCEDURE MANUAL 

Poli.c.y Forrn 106.1 

Serious 1\-1 en tal Illness 

DE TE R!vf IN A TIO 1'. 

Based upon my direct behavioral health assessment of this person, or my review thereof+ I 

J!tnara Lan1ontagne L}\.SAC 

Print Nan1e Credentials 

make the fo!towing preliminary serious mental iUness eligibility rccon1111endation: 

Dv.tr- uf Birtk 

1. Preliminary Reconunenda.tiou of Qu~lifying Diagnosis! (Select the person's principal diagnosis(es) supported by 

available information. J 

Psychotic Disorders: 0 F20.0 0 F20.l O F20.2 0F20.3 0 F20.5 ~ F20.9 0 F28 □ F29 0 F21 0 F22 □ F25.0 

[] F25.1 □ F25.8 □ F25,9 

Bipolar Disorders: 0 F3 l.O □ F31. l O F3l.l0OF31. 11 □ F3 l.12 □ F3 l.1J □ F31.2 □ r3 L30 0 F3 l.3 l 

0F3L320F31.4 nr3L5 0F31.600F3L610F3L620F3L630F3L64 0F3l.700F31.710F31.72 

[] F3l.73 0 F3l.74 0 F3L75 0 F3l.76 □ F31.77 □ F31.78 0 F31.9 LJ F3L81 0 F31.89 0 F34.0 □ F39 

Major De.prcssion: D F32.0 D F32, 1 D F32,2 D F32,3 D F32.4 D FJ2.5 D F32.9 D F33J) D F33, l D F33.2 

0 f3JJ □ FJJ.4 0 P31.40 0 F33.4I O F33.42 0 F33.9 0 F32.8 0 F32,9 0 F34.1 

Anxiety Disorders: 0 F40,00 0 F40.01 OF40.02 0 F4 LOO F41. l O F40.2 0 F4I .8 □ F41.9 

Trauma-Related Disorders: D F43 .10 D F 43 .11 D F43J 2 

Dissociative Disorders: D F44.81 

Obsessive-Compulsive Disorders: D F42 

Personality Disorders: [] F60.0~ [] F60.1 ~ [] F60.3, [] F60..1, [J F60~5, D F60.6, D F60.7~ D F60.81 ~ 

0 F60.89, 0 F60.9 

l(a) The above noted dh1gnosis(es) is/are suggested based upon the foHowing signs and sy1nptorns of the niental disordcr(s): 

(Provide descriptions of both positive ( confinning) findings and negative C~rule~ouf1

) findings for other diagnoses that v;ere 

considered}. 

PreSivH~ BHR's sister reponed he is pritnari1y psychotic,. delusional and having A V.H and is una\vare of mood 

syinptotnst anxiety or \Vhat substances he 1nay use. Given 1,vhat [s known, the BHR appears to 1neet crilt;;r:ia for F20.9 

Schizophrenia. 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 37 of 179
COP 015257

p,-. r,.. '·t,..,1····. ~:·I' Ir.t'IO) »1°~-1 ',r 'lii-issn· ;,., u ....... ~\ t l t .11 ..... u J'itl:i. i..d', t J.n~ 

Date ~;f Hh1h: ■-

2.. f_r~tlmJnary Recomrnendation of Funetional Criteria: As a result ofthe above diagnosis, the person exhibits any itern 

NlA 

listed unde-r 2(a), (b), and/or (c) for most ofthe past hvelve months ~r: for n1ost of the past six 1nonths \.Yith an expected 

continued duration of at least six 1nonths: 

D 2(a) Inability to Hvc in an independent or family setting ,vitb out supervision (Self Care/Basic Needs) - The 

person's ca pa city to Hvc independently or in a family settingf ind uding the capacity to pro vi de or arrange fi.,r 

needs such as food 1 clothing, shelter and medica1 care. 

['] N cglect or disruption of ability to attend to basic needs. 

D N eed5 assistance in care f o t· se] f. 

D Unable to care fur self in ::iafe or sanitary manner. 

D Housing~ food and clothing must be provided or arranged for by others. 

D L~nable to attend to the n1ajority of basic needs of hygiene,, grooming~ nutrition., medical, and dental care. 

D Unwiliing to seek prenatal care or necessary n1edicai/dent:al care for serious medical or de-ntai conditions, 

D Refuses treatlnent for life threatening illnesses because of behaviora] health dfaorder. 

.. J 2lb) A risk of serious harn1 to self' or others (Social/ Legal and/or J?ccling/AffcctlJVIood) ~ The extent and ease 

with which the person is able to rnaintain conduct v,rithin the H1nits prescribed by la,v, ruies and social 

expectations,. and/or the extent to v,thich the person~s en1otional Hfe is wen 1nodulated or out of control. 

D Seriously disruptive to fmnily an<l/or conununity. 

D Pervasive! y or iln1n incn t]y dangerous. to od1er.s) hod Hy safety. 

D Regularly engages in assaultive behavior. 

[] Has been arrested1 incarcerated, hospitalized or at risk of confineinent because of dangerous behavior. 

D Persistently negiectful or abusive towards others in the pe-r.son 's care. 

D Se-vere d~Bruption of daily life due to frequent thoughts of deathi suicide~ or sclf-hann~ often with behavioral 

intent and/or plan. 

D Affective disruption causes significant darna.gc to the person's education, live1ihood1 career, or 

personal relationships, 

□ 2(c.) , \ Dysfunction in Role Perfor1nance - Person's capacity to perkHn1 the present 1najor role thnct1on in society --

sc.hoot work, parenting or other developn1entally approprlate responsibility. 

CJ Frequently disruptive or in trouble at vtork or at school 

D Frequently tern1inated frorn v1ork or suspendediexpeUed fro1n school. 

D tv1ajor disruption of role fi111ctioning. 

:J Requires structured or supervised work or school setting, 

:J Perforn1ance significantly belo\v expectation for cognitive/developinentaI level. 

~ Unable to \Vork; attend school, or !nect other develop1nentally appropriate responsibilities. 

The above noted Functional Criteria ratings are suggested based upon the foUO'wing information regarding this person ls 

functioning: (Provide a description of positive (confirming) findings and negative {'"rule~out'') findings of the functioning 

CJ f this; pcrs on). 

p·~h~(: ~ 

J'nh·y F.nrn JU6. l, ~\·!l Dei·~·m11n;it1i:m 

t.a~l n.(~\i $(cd· 9..·19,.;,r.t 5 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 38 of 179
COP 015258

3, Ris_l_{ of Deterioration 

[gJ The person docs !Htt currently meet any one of the above function a! criteda 2(a) through 2(c) but may be expected to 

deteriorate to such a level w·ithnut treatment 

t8J A c1uulif ying diagnosis with probabie chronic) relapsing and rernitting course. 

D Co ... n1orbidities (like n1ental retardation, substance de,pendence~ personality disorder, etc.). 

LJ PersLstent or chronic factors such as social isolation, poverty~ exlre1ne chronic stressors (Jifc~threatening or 

debilitating 1nedicai iHnesses, victi.tnization, etc.) 

D Otbcr (past psychiatrfc history; gains in functioning have not solidified or arc a result of current compliance 

only; cou rt-con11n itted; care is con1 plicatcd and rcqu ires 1n u 1 ti pl e providers; etc.). 

The above noted Functional Crireria ratings are suggested based upon the foHo\ving inforn1ation regarding this person's 

functioning; (Provide a description of positive (confinning) findings and negative c·rule-out1 ~) findings of the functioning 

of this pers.on), 

PreSJ\,11; Given what is kno\vn, the BHR appears to meet -criteria for F20.9 Schizophrenia. 

LASAC II Evaluator 9/22/2016 

Assessor's ~.amc (print) / Signature Cr eden tials/Positio n Date 

P;1t.:: .1 

Poli::y r'nnn I 06. J, S ~·.:11 !}.;t1.:m1i1utimi 

L.1i;1 Rcvi1~d, t}_,:_q_:zo-: S 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 39 of 179
COP 015259

-·-- ------------------------------------------------

II. Final Si\111 EHgihility Dctcrn1inat.ion Evaluation 

Nmnc: rvhihmnnrn<l :\-luhnymin 

Da:e 0fHtrth: -

D Sf\-11----, All of the available information supports the con cl us-ion that the above individual has a qualifying 

diagnosis ( l) A NIJ either 1neets one or 1norc functional criteria (2) OR is at risk of deterioration (3) and 

therefore nlci:.~ts :\DHS/DBHS clinic.al criteria for St\lIL 

D S1'v1I A - Functional Criteria 2a or 2b 

D S11I B ~ Functional Criteria 2c or 3 

D Not SMI - The above Individual does not nu~ct ADI 1 S/DB [ iS cEnical criteria fo-r S~1T. 

Clinica! rationale for finaI deterrr1ination: 

---------------------------------------------------------------------------------------------·----------------------

---------------NNNmN-UUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUUOOUUUUUOOUUUU.-, h .,ouU<O««O<«m<<OmO<<<«m<<<•<«OO<<«<<U<«<<<OO««< 

__________________ ....._ .... ,.. ...... ,,,.,,, .. ,.,,,, .... ,, .. ,, .. ,.,,,, .... ,, .. ,, .. ,.,,,, .... ,,, .. , .. ,.,,,, .... ,,, .. , .. ,.,,, ..... ,,, ....... ,,, ..... ,,, .. , .... ,,, ..... ,,, ....... ,,, ..... ,,, .. , .... ,,, ..... ,,, ....... ,,, ..... ,,, .. , .... ,,, ..... ,,, ..... , .. ,, ..... ,,, .. , .. ,.,,, ...... ,, ..... , ......... ,,, .. , .. ,.,,, ..... ,,, ..... , ......... ,,,., ...... ,, ... , .... ,,,, ........ , 

Rc-vicv .. cr Name (Print) Signature 

Credentials/ Position Date of Dctern1ination 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 40 of 179
COP 015260

/rupmin9 lna119e 

to, life 

5030 W McDowell Rd Ste 16Phoenix AZ, Arizona 850353900 (602) 278-1414 Fax (602)269-8410 

Fax Transmission 

DATE: 01/23/2017 

TO: 

FROM: Amy Beard 

REGARDING: PCP notification 

FAX: 

NUMBER OF PAGES IN THIS TRANSMISSION: 2 

********************CONFIDENTIAL********************* 

This electronic mail message contains information that is or may be LEGALLY PRIVILEGED, 

CONFIDENTIAL.PROPRIETARY IN NATURE, OR OTHERWISE PROTECTED BY LAW FROM 

DISCLOSURE, and is intended only for the use of the Addressee(s) named herein. If you are not the intended 

recipient, an addressee, or the person responsible for delivering this to an addressee, you are hereby notified that 

reading, using, copying, or distributing any part of this message is strictly prohibited. If you have received this 

electronic mail message in error, please contact us immediately and take the steps necessary to delete the 

message completely from your computer system. Thank you. 

······coNFIDENTIAL •••••• 

Message: You are being notified of care being provided for your patient at Terres. 

If you did not receive the correct number of pages, or if there are any questions regarding this fax, please call 

(602)278-1414. 

Thank you. 

Sender: -~A~m~y~B=ea=r=d _____ _ 

OUR FAX# IS (602)269-8410 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 41 of 179
COP 015261

PM FORM 4.3.1 

COMMUNICATION DOCUMENT 

To: (Primary Care Provider Name}: ___________ _ 

Address: 

Phone#: ( ) -

Fax#: ---------------- From: Clinician Name: Amy Beard 

Provider Agency Address: 5030 W McDowell Rd Ste 16 

Phoenix AZAZ 850353900 

Provider Agency Name: Terros 51st Avenue 

Provider Agency Phone #. (602)278-1414 

T/RBHA Name: MMIC Recovery Centers T19 SMI Provider Agency Fax#. (602)269-8410 

Dear Primary Care Provider: 

We are sending this information to you for coordination of care. We believe you are the assigned care provider for this patient, although you 

may not have seen this patient yet. If you vvould like to have more information, or need to discuss this patient, please contact the behavioral 

health care provider listed. 

Patient Name: tv'luhammad Muhaymin AHCCCS ID # -0335 

Patient Date of Birth: AHCCCS Health Plan Name: 

Medicare ID#: Medicare Advantage Plan Name: 

I. REASON FOR THIS COMMUNICATION: (Check all applicable reasons) 

_ Patient referred by AHCCCS Health Plan/PCP/Medicare Provider 

_ Person determined to be Seriously Mentally Ill (SMI) 

_ Advance directive or refusal to sign 

Annual notification 

_ Information requested by AHCCCS Health Plan/PCP/Medicare Provider _ Significant change in diagnosis 

_ Patient has Pervasive Development Disorder and/or Developmental Disability 

_ Critical laboratory result _ Medication change ___x Other (Please specify belovv): 

_ Transferring care back to PCP 

II. CLINICAL SUMMARY 

1) DSM-IV Diagnosis (required): 

_ Out of state placement 

Axis I: 295.10 Schizophrenia Disorganized Type305.20 Cannibus Abuse 

Axis II: . No diagnosis on Axis II 

Axis Ill: Chronic Pulmonary Disorders 

Services closed 

2) Dose, frequency and target symptoms of current behavioral health medications (required). (If transferring back to PCP please indicate 

status of step therapy): 

3) Summary of critical labs: 

4) Other attached information (required only if requested by PCP, otherwise optional) 

_ Behavioral Health Assessment (Date): _ Individual Service Plan (Date): 

_ Results of non-critical laboratory, radiology or other tests (Date): 

_ Other (Please specify): 

Ill. RESPONSE TO PCP'S REFERRAL QUESTION(S) 

Date PCP Referral from the Health Plan vvas received: (if applicable) 

IV. ADDITIONAL BEHAVIORAL HEALTH PROVIDER CONTACT INFORMATION 

Psychiatrist, Nurse Practitioner, Physician ,A.ssistant Name: 

Psychiatrist, Nurse Practitioner, Physician Assistant Phone#: (602)278-1414 

Clinical Liaison Name: Phone #: (602)278-1414 

Other Contact Name: Amy Beard, CC Phone#: (602)278-1414 

Mailed ~ Faxed Sender name: Amy Beard 

Electronically Signed By: Amy Beard /s/ 

Signature of clinician completing form 

Date: 01/23/17 

Date: 01/23/17 

Note: This form must be compJeted in its entirety to demonstrate appropriate communication to the PCP. Retain copy in person's comprehensive medical 

record. 

Effective Date: 12/15/2008 Last Revised 7/19/2007 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 42 of 179
COP 015262

Sl\'11 EVAL.UATION REQUEST FORM 

R.~(_ u_i~.:ed .lleft•r:~·al ... l!~.f.0 .... 1...,·m .... a""'t .... io.,,..n,.___ __ ..,._ __ 'i~....;;*l::..:'l:.:.ei:::ts=·e-=a::.::d:.:.:d.:.rc=s=-s-=a=ll-=a:i::)L.Jl:.:H~ca:::h:::lc=-· ::.:fi.::.:cl:.::d:::_.s~c\~'C:.:.'"...!.."...::.tJ:.::·m:.:.:t':_*_"'_-------. 

RBHA: fv.lercy J\'.larico1>a lntegrafed Referral day: 9/16/2016 Referral time: 1356 

-,----------

Evaluation 'fype: f<outinc Pre-SMI: Yes · C~()E/C(YI': No ----......... _._ ....... _________ ...._ __ --,------·----1----------~ 

BHR Name (AKA): Muhammad Muhaymin DOB: SSN: 11111111111 

1 BHR Phone #: G 0786 Gender: F cm~d<.'. Ilace: White _______ ... ____ . __ .__,,_,, _________ -i--------------1 

Primary language: English Interpreter language: None Medicare: No 

T19: Yes ------- AHCCCS JD: 335 ·-rPlan: M:crcy {~arc 

------

Legal Guardian: ·ves , Guardian Name & number (Jegal guardianship papers required at 

the time of evaluation): Mussallina Muhaymin 0786 

Referral source (name and #): Guardian Mussallina Muhaymin BHR agrees to eval: Yes 

786 

B}IR locatic,n (please include hospital, unit, roo1n #, etc): 

Booki;;g.iooc # (if app~i~able ): _______ J Co~rtDate / ~ele"8e-D-at-e:---......................................................................................... 

----------- B HR Address (residential or n1ai1ing): Mailing • PHOENIX, AZ. 85041 . --- . - -----------------! 

Co1nments: Found SMI 12/14/2010 Dr Hoffman. Per MMIC this BHR never engaged in servs. CIS: 

099, MMIC: S03048910 

Evnluation Information (For (~PI~ use onlv): 

~E_J~_•a_lu_a_ro_r_~_~a_1_ne_: ___ T_a_m_a_r_a_L_a_M_o __ n_ra_g_n_e ____ :__ D_c_tc_'nn_in_a_ti_on_ou_t_·co_m_c: __ P_re_~-_S~M_l_· ____ _ 

Evaluation Date: ........................ l ..... 9/.16/201.6 .............................................................................................................. ~.~~·~·~·~·~·~ .. ~.~ .... ~.~·~·~·'. ................................................... -11_:_30_A_M ___ ~ BHR site preference: Terros: W. McDowell Reason for site selection: (;eogr,nphical I,ocati 

----------·--------------------1----------1------------1 

Eligibility Documents: 1~19 

ls the BllR hotneJess? 1 Yes (on the street) 

Days of Medications 

remaining: 

AC'J' Appropriatt;: 

:N·ot currentlv ta.kino '.. .. . .. .. , .... b 

-·------"""""""""""''""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""'•'------------'•""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" 

Comments (Serious N/ A 

Crimes, Languages, 

Special needs, other): 

r ................................................................................................................................................. """""""""""""""""""""""""""""""""""""""""""""""""""·-· . Determination date: D~tennination ( None .S~lccf<.\(I) . 

I outcorne: ____ ..., 

SJ\,tl diagnosis (if Site assign1ncnt: < 

' applicable): 

Sl\.11 Processor I 

Comments: ....... _ .................................................. .................................................. 

Ilcviscd 12-15-15 

Name: Muhaymin, Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 43 of 179
COP 015263

~•JI II I I I Ill I I II Ill I I I I l I II -•"""""""'"""'"'"""""'""""""'""""""""""""'""""'""""""""""""""'""""'""""""""'"'"""'"""""'"""'"'""'"'"""'"""""'"""""""'"'"""'""""'"'t-...~-_...,.------~...,-,-,-.-~,._..., 

CONFIDENTIAL TRANSMITTAL 

From: 

Crisis Preparatjon & Recovery Inc. 

2120 s Mcclintock Dr 

Tempe, AZ 85282 

(480) 804-0326 

Evaluator Name: Tarnara Lamontagne 

To: Cenpatico Integrated Care 

To: Health Choice Integrated Care 

To: Mercy Maricopa Integrated Care 

To: Crisis Response Network 

----------------------

TRANSMI"l I AL METHOD: [gJ Emailed 

DATE EMAILED: 9/22/2016 

COE/ COT: r 

~i<loloHlo~ 

□ YES rg) NO 

MEDICARE: YES (g] NO 

T-19: ~ YES NO □ PENDING 

If Non-T19 and not pending, AHCCCS screening completed: D YES D NO 

t,HCCCS efigibJe: D YES (resources for application provided) NO 

D ' 

D 

□""'""' 

1 

STATUS: □ GMH (CPR) ~ PRE-SMI (RBHA) D Determination requested (CRN) 

IF DETERMINATION REQUESTED: 0 3-day request □ 20-day pend □ EEP 

The information contained in thts electronic document is int.ended only for the confidenUat use of the designated racipient(s) named 

above. This document contalns 1nformet1on that is privileged and confident,al. If the reader of th:s message ~s not the intended 

ret~ipient{s}, you are hereby notified that you have received this lransrn[ssion in ermr, and Ihat any review, dissemination, distribt:tlon 

or copying of this document is strictty proh!blte-d_ tf you rlave rece[ved th!s communication in error, please notify us immediately arid 

discard the message. Thank you. 

Revised- i 2-03-i 5 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 44 of 179
COP 015264

Jv1uhayn1in, Jv1uhamn1ad 

Time: 12/05/2016 01: 17 PJ:\1 

Patient Information 

Name: l\,1uham1nad J:v1uhavmin ~ 

Current i\ddress: 

Home Phone: Ho1ne: 

Client F acesheet 

'ferros 

DOB: Age: 43 Social Security#: --8 

City, State, Zip: Phoenix, AZ 85041-

0786 Marital Status: SE.,,\:: lvf Race/Ethnicitv: J 

Referred By: Processed By: Kimberly Bryant 

J)irect Care Clinic: 

Date of assessment: 

J.,evel of Care Information: 

Level of Care: SUPPOR1T\lE Special i\ssistance: r Advocate: I 

OHR i\.dvocate: 

Phone: Ext: Fax: 

Email: 

l{esidential Inf 01mation 

E1nergency Information 

En1ergency Contact :J\1ussal lian 

Primary Physician: 

Psvchiatrist: Jon Allison MD ~ 

Insurance Infonnation 

Payer Name 

MMIC Recovery Centers T19 

SMI 

Program Inforn1atio11 

Open Date Close Date 

09/22/2016 

Admitting DSlv1-N AXIS (1): 

Muhay1nin 

Phone: 

Relationship: Sister 

Fax: 

Phone: (602)278-1414 

Phone 

{800) 564-5465 

Program 

Supportive 

Policy Nbr 

-3099 

Assigned Clinician 

Kimberly Bryant 

Phone: 786 

Fax: (602)269-8410 

Site 

Group Nbr 

~335 

West McDov11ell 

Axis I - ICD 9 Code/ DSM 4 Description ICD 10 (~ode/ DSM 5 Description 

295.10 Schizophrenia Disorganized F20.9 Schizophrenia 

Ty1Je 

305.20 Cannibus Abuse F12.10 Cannabis use disorder, Mild 

Page 1 of 2 

.,,.,,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_,_ 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 45 of 179
COP 015265

l'v!uhaynun, l'v!uhamn1ad Page 2 of 2 

, i No diagnosis on Axis II 

Axis III: 30 Chronic Pultnonary Disorders 

Axis IV: Problen1s with/related to honsing, 

Axis V: 45 

CCP Kimberly Bryant BlclT 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 46 of 179
COP 015266

Jv1uhayn1in, Jv1uhamn1ad 

Time: 11/08/2016 11 :36 i~lvI 

Patient Information 

Name: l\,1uham1nad :l\.1uhavmin ~ 

Current i\ddress: 

Client F acesheet 

'ferros 

DOB: Age: 43 Social Security#: 

City, State, Zip: Phoenix, AZ 85041-

Home Phone: Ho1ne: 0786 Marital Status: SE.,,\:: lvf Race/Ethnicitv: 

Referred By: Processed By: Kimberly Bryant 

J)irect Care Clinic: 

Date of assessment: 

J.,evel of Care Information: 

Level of Care: SUPPOR1T\lE Special i\ssistance: r Advocate: I 

OHR i\.dvocate: 

Phone: Ext: Fax: 

Email: 

l{esidential Inf 01mation 

E1nergency Information 

En1ergency Contact :J\1ussal lian 

Primary Physician: 

Psvchiatrist: Jon Allison MD ~ 

Insurance Infonnation 

Payer Name 

MMIC Recovery T19 SMI 

Program Information 

Open Date Close Date 

09/22/2016 

J.\dmitting DS1"1-IV A,'XlS (1): 

Muhay1nin 

Phone: 

Relationship: Sister 

Fax: 

Phone: (602)278-1414 

Phone 

{800) 564-5465 

Program 

Supportive 

Policy Nbr 

-3099 

Assigned Clinician 

Kimberly Bryant 

J 

Phone: 786 

Fax: (602)269-8410 

Site 

Group Nbr 

-=>335 

West McDov11ell 

Axis I - I CD 9 Code/ DSIVI 4 Desc,iption ICD 10 Code/ DSM 5 Desc1iption 

295.90 Schizophrenia F20.9 Schizophrenia 

Undifferentiated Type 

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy _______ yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy 

Page 1 of 2 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 47 of 179
COP 015267

l'v!uhaynun, l'v!uhamn1ad Page 2 of 2 

V7109 I No diagnosis on Axis II , 

' ' , 

.4.xis III: NONE 

Axis IV: Proble1ns with/related to housing, 

AxisV: NONE 

CCP Kin1berly Bryant BliT 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 48 of 179
COP 015268

Jv1uhayn1in, Jv1uhamn1ad 

Time: 10/24/2016 01: 17 PJ\1 

Patient Information 

Name: l\,1uham1nad J\1uhavmin ~ 

Current i\ddress: 

Home Phone: Ho1ne: 

Client F acesheet 

'ferros 

DOB: Age: 43 Social Security#: --8 

City. State, Zip: Phoenix, AZ 85041-

0786 Marital Status: SE.,,\:: lvf Race/Ethnicitv: J 

Referred By: Processed By: Kimberly Bryant 

J)irect Care Clinic: 

Date of assessment: 

l{esidential Inf 01mation 

Status: 

J1:111ergency Information 

Emergency Contact: 

Primary Physician: 

Psychiatrist: Jon 1\llison MD 

Insurance Information 

Payer Name 

MMIC Recovery T19 SMI 

Program Information 

Open Date Close Date 

09/22/2016 

Admitting DSJ\,1-N AXIS (1): 

Relationship: Phone: 

Phone: Fax: 

Phone: (602)278-1414 

Phone 

(800) 564-5465 

Program 

Supportive 

Policy Nbr 

99 

Assigned Clinician 

Kimberly Bryant 

Fax: ( 602)269-8410 

Site 

West McDowell 

Axis I - I C~D 9 Code/ DSM 4 Description IC::D 10 Code/ DSM 5 Description 

295.90 Schizophrenia F20.9 Schizophrenia 

Undifferentiated Type 

I V71.09 I No diagnosis on Axis II 

Axis III: NONE 

Page 1 of 2 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 49 of 179
COP 015269

l'v!uhaynun, l'v!uhamn1ad Page 2 of 2 

Axis IV: Problems with/related to housing, 

Axis V: NClNE 

CCP Knnberly Bryant BHT 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 50 of 179
COP 015270

Jv1uhayn1in, Jv1uhamn1ad 

Time: 09/30/2016 11:36 i~lvI 

Patient Information 

Name: l\,1uham1nad :l\.1uhavmin ~ 

Current i\ddress: 

Home Phone: Ho1ne: 

Client F acesheet 

'ferros 

DOB: Age: Social Security #:--8 

City. State, Zip: Phoenix, AZ 85041-

0786 Marital Status: SE.,,\:: lvf Race/Ethnicitv: J 

Referred By: Processed By: i\llyson Parsons 

J)irect Care Clinic: 

Date of assessment: 

l{esidential Inf 01mation 

Status: 

J1:111ergency Information 

Emergency Contact: 

Primary Physician: 

Psychiatrist: Jon 1\llison MD 

Insurance Information 

Payer Name 

MMIC Recovery T19 SMI 

Program Information 

Open Date Close Date 

09/22/2016 

Admitting DSJ\,1-N AXIS (1): 

Relationship: Phone: 

Phone: Fax: 

Phone: (602)278-1414 

Phone 

(800) 564-5465 

Program 

Supportive 

Policy Nbr 

-3099 

Assigned Clinician 

Allyson Parsons 

Fax: ( 602)269-8410 

Group Nbr 

335 

Site 

West McDowell 

Axis I - I C~D 9 Code/ DSM 4 Description IC::D 10 Code/ DSM 5 Description 

295.90 Schizophrenia F20.9 Schizophrenia 

Undifferentiated Type 

I V71.09 I No diagnosis on Axis II 

Axis III: NONE 

Page 1 of 2 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 51 of 179
COP 015271

l'v!uhaynun, l'v!uhamn1ad Page 2 of 2 

AxisV: NONE 

CCP Allyson Parsons BIIT 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 52 of 179
COP 015272

Nanh:: i\luhammad fvluhnrrnin 

--- V Da1-c " ' lif Bir1Jr -

! NA~'lE: Muhammad Muhaymin DOB: CO~TINUATJON. , .. I 

I 

I 

I 

Mari tai Status 6. Single Primm-y Current Sub I N·one I (None Selected) I 

I I I r-""~-

r 1•·1 

' l I I 111 I l I 

Race 2. Black Prinrnry Cun-ent Sub I (Nont~ Sl\lccte_~) First Use: i I - -· -·- .,. 

Ethnic:lty 2. Not Hispanic Secondary Current s I (None Selected); I (Nont Selected) I I ~----~~~~- .............. _______________ I 

·----------------------------------------------, ··- Language t 1. English Secondary CmTent S (None Selected} I First Use: I ... ., I 

'------------------------------------------------------------------------, I t Tertiary Current Sub I Medfca] Insurance l 2. AHCCCS I (None Selected): (None Selected); I 

I I i .. -~-~~ r I - 1\1edical Jnsurnnce 2 (None Selected) Tertiary Current Sub (None Selectell)" I First ase: l 

L~·lcdical Insurance 3 .. ............._. 

(None Selected) i 

/\HCCCS ID A9?.270335 

TI9 Yes 

1 If Private insurance prcs<:nt, pJcasc N/A l indicate type, insurance ID# a11d 

Policy l\umbcr --------..-.__ __ ....,. _______ -..----..-..-...... --

] Referral Onte I 

9/16 I 

I ..,......_..._. _______ _,.,...... ..... ------

Referral Source I L Selt''Family/ }7'-dend 

Health Plan Referral I No 

Detav code I 9 .. Not applicahlc I 

I 

Arrests in the last 30 days I 0 ! 

Household S i1.e 0 r--•••-~W'"•- ••-••~ --,~-~,•~, ~- ,m •-•--•~--~•.VV<VVVV,~•.~~-~•.~~-~•.~~-~•.~•~.~•.~•~.~•.~ 

, Gross Monthly Household Incorne 0 

l rregn,m.t or Post~Partum l No j\V~1;1-~; ~~:·iil;i)-~r}~~d~nt-Chiid;en- -- . -· _,, _____ - --- ---- ~- \ No > 

j Primary Residence __________ -~ 7. Homekss/~!•~-l~crJor Hi 

LT reatment P articj_pation ____ ,,, ........... ~ ................ ____ y~ \~!! n ta ry 

Veteran Srntus No 

ADOC No ------------------------------------------------------------------------1 ---..--.-....--- - - .. - ·-· ,,._,vv,,.. .._, VYVY".•..,.,,.,vv~,_ 

AOC {adnh) ; No -------

DES/RSA I No I 

I Ill I I I II II ' J I I I I I I I I I ............... ~~ ............... u .. t,+•--~~-•~---........,.~~ ........................... 

DES Job.s [ No ~ 

! .. ,~ ..... ~, ...... ,,, .... ,, ...... ,, .. ,, ..... ,,, .... ,, .. ,, .... ,,,, .... ,, .. ,, ..... ,,, .... ,, ... , .... ,,, .... ,,,, 

Schnn1 I Nfi I 

Diagnost1c Sm11!nary ~v=••-.. =• 

F20.9 Schizophrenia 

ZS9. O Hornelessness 

........... ohh'.h. .. ,.,_._,.-..,_._,..,............,.ohh'.h. .. ..,.,..,.--,~oh.'.,'.,.,. .. v.l,,'.,..,..........,._.- ~ 

Pri j rnary T rnnsport 2. fan1ily/Friend 

Social Support of Recovery l. No attendance in past n i 

Gender Identity 6 \Voman i 

-· Sexuai OrjentaHon 4 IIctcrosexual 

Name: Muhaymin) Muhammad DOB: Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 53 of 179
COP 015273

Initial and or Change in Diagnosis 

1vlodifiedDate 12!0520161050 A1\l 

Primary Billing Diagnosis: ,lXIS I : 295.10 -Schizophrenia Disorganized Type 

.,\tis I -DS~I -IV DS~I-V Specifier: 

295.10 Schizophrenia Disorganized Tire :F209 ! Schizophrenia 

'" --------------------------------" 

i "()'\ 10 ,j"""" Canmbus Abuse Fl2 IO : Cannabis use disorder. 1c!Jld -------------------------------

• 

A.xis II: 

iV71.09 Nodiagnos1sonA,,isil 

.~xis III: 3 0 Chronic Puhnonary Disorders 

.~xis IV: Problems 11ithlrelated to housing. 

Significant recent losses as of 0912212016: 

A.xis \r: 45 

Modified bv: Lillian1 Villalobos !v!D 

• 

Date: 12:052016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 54 of 179
COP 015274

Initial and or Change in Diagnosis 

1vlodified Date 09126!2016 03 51 P1v! 

Primary Billing Diagnosis: ,lXIS I : 295.90 -Schizophrenia Undifferentiated Type 

.,\tis I -OS~! -IV DS~I-V Specifier: 

295.90 Schizophrenia Fndifferentrnted T)ve :F209 ! Schizophrenia 

•· ----------------------------------------------------------

• 

-------------------------------

• 

A.xis II: 

iV71.09 Nodiagnos1sonA,,isil 

.~xis III: NONE 

Significant recent losses as of 09/22/2016: 

.,\xis V: NONE 

Modified bv: Julia lvlatthies BHP 

• 

Date: 09/22/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 55 of 179
COP 015275

Tcrros 

Discharge Summary 

Discl1arge from Terros 

CLIENT ID: 1101103099 

CLIEN1': Muhammad Muhavmin ,., 

Payer: IvfMIC Recovery Centers T19 S1v1I 

• • 

SSN: DOJl: SEX: Nlale 

C.IIART #: l.1AST Bll,LABLE SERVICE: 01/09/2017 

DATE OF INT.i\KE: 09/22/2016 DISCH.i\RGE DATE: 01/23/2017 

DSl\1-IV DIAGNOSIS: 295.10 305.20 V71.09 

RE.A.SON FOR DISCHARGE: 07 J)eceased 

Deceased 

SU1\tll\1ARY OF SERVICES PROVIDED: 

Intake 

Integrated Health, lviedication Monitoring, 

SU1\tll\1ARY OF GOALS ACHIEVED: 

PLAN FOR FOLLO\V UP SERVICES: 

REFERRED TO: 

Electronically Signed By: 1.\my Beard /s/ 

i\.111y Beard 01/23/2017 

Electronically Signed By: ,-'.\n1y Beard /s/ 

Clinical Dir./Supv. - An1y Beard Date O 1/23/2017 

Revision Date: 6/li00 Amy Beard 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 56 of 179
COP 015276

Mercy Maricopa Scattered Site Housing Application 

.~mercy . ~rf n,aricopa 

integrated care 

PNO: T erros Direct Care Clinic: West M cDowe II Case manager (print name): Kimberly Bryant 

Case manager email: kimberly.bryant@terros.org Case manager phone: 602-278-1414 

1. Member information 

l>-1cmbernarne: Muh~_mmad Muhaymi.!:!.AHCCCSID#: _________ DOB: 

Type of subsidy housing requested: Iii Member only 

Sex: OMaJe Female 

Is this member homeless? 

D Member and dependent family members 

Priority population: [i]Yes No If yes, desctibe: Living in park 

lilYes 0No 

ACT team: 0Yes 0No Title 19: 0Yes 0No COT: Yes li]No 

Currenthousingsituation/setting: Living in Maryview Park 

2. Housing hi.story and current needs 

Has the housing applicant lived independently in the past two years? Yes li!No 

If yes, what was the most significant reason for leaving: (please check all that apply) 

Eviction Hospitalization Inpatient Substance Abuse OJ ail/Prison Voluntary 

Other: __________ _ 

Does the applicant have legal issues? 0Yes · liJNo If yes, please describe: _____________ _ 

Sexoffender: 0Yes [ilNo Ifyes,level: _______ _ 

Does the applicant haye a parole/probation officer? 0Yes li!No 

If yes, PO's name: _________ Phone: ______ _ 

Does the applicant have a legal guardian? ~Yes 0No 

If cs uardian's nam : Mussallina Muhaymin A enc : Family {sister) Phone: Y 'g e -----............................................................................................. g Y --- 786 

Page 1 of2 

l 

Name: Muhaymin, Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 57 of 179
COP 015277

Current sources of incorne and an1ount (please check all that apply]: 

oss1 $ 0 SSDJ s_o_ ............. _, 

0GA $___ VA$ __ 

Ounernpi oyment benefits$ __ _ 

social Security $_o __ _ 

AFDC/TANF$19o,oo 

Employment$ __ _ 

Sources of financial ass is ta nee the applicant has applied or wHl apply for: .!.=!.~!hamm.ad wants to appl,j for SSDt, does r'OCeN~ food s.tamμs in tle i?m[]Unt ct $190.00 

l 

I 

I 

I 

I 

! 

I 

I 

I 

Does the applicant require a start~up box? i]Yes 0No 

Has the meu1ber aJ)plied for Con1n1unity Housing? 0Yes )i1No 

(If yes, rnem.berwi1J be removed from Community Housing waitlist.) 

r"'··--""-1!';<;< .... ,lfll\ao. _____ .ol:il; tr ,,_ .... _,, __ ~,-~....,,,,, ... -, ...... ,;,,,.,,,,,,..,,..,-~.,, ............ , ......... , ·"'·-·----·-·""-···"" .... ~.,.--1 

i· REQUIRED: Please con1plete and submit the VI-SPDAT along with this application~ J:. 

I -··- --~ -~A~~~:::::_~:::~ ..... ~ . . 

3 Certification/Signatures 

Date 

Please complete this form, print/scan and email to: housing@n1crcymaricopa.org 

Page 2 of2 

Name: Muhaymin) Muhammad DOB: 

I 

t 

I 

Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 58 of 179
COP 015278

Amy Beard 

From: 

Sent: 

To: 

Subject: 

done 

1-IEALTH. 

. 

. 

. 

. 

. 

. 

. • 

• 

• 

: 

. 

• 

. 

. 

• ' 

. 

• 

~ 

Julia Matthies 

Monday, September 26, 2016 3:55 PM 

Amy Beard 

RE: Ox needed, see below 

Julia Matthies 

Clinical Director 

5030 W McDoweli Rd. Ste 16 • F.)hoenrx, AZ 85035 

P: 602-285-6817 

wtv1v,·. tcrros.o rg 

-··· ' .. ' ,... . . ... ,. ' . . ' . ,. . .... ' .. , ............... ,. . ..... .. ... ...... .,.... . , .. ., .. . 

From: Amy Beard 

Sent: Friday, September 23, 2016 4:38 PM 

To: Julia Matthies <Julia.Matthies@terros.org> 

Subject: Dx needed, see below 

From: Amy Bea rd 

Sent: Friday, September 23, 2016 4:13 PIVI 

To: Aflyson Parsons <Allyson.Parsons@terros.org> 

Subject: FW: new referral-Muhammad 

Allyson, 

I am assigning Muhammad r'v1uhaymin to on your caseload. It is documented he has a Guardian, his sister, Mussallina 

Muhaymin -0786, and he is homeless at this time. I will be requesting an MD appointment in 7 days, so you can 

give that appointrnent to Muhammad and his sister, as she may know.where to find him. 

Per report in the Core assessment: All of the information gathered below was from the sister/guardian. BHR1s sister 

reported he is primarily psychotic, delusional and having AVH and is unaware of mood symptoms, anxiety or what 

substances he may use. Given what is 

known, the BHR appears to rneet criteria for F20.9 Schizophrenia. 

Please contact his sister and give the Doctor's appointment, September 30th from 11arn-12pm and I will request it to be 

scheduled. 

Thanks, 

l-lEALTH 

Name: Muhaymin, Muhammad 

Amy Beard 

Clinical Coordinator 

5030 W McDoweH Rd, Ste 16 • Pt1oenix, AZ 85035 

P; 602-285-6819 

1 

DOB: Date: 10/26/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 59 of 179
COP 015279

ADHS/DBHS Policy Form 113.1 

NOTIFICATION OF PERSON IN NEED OF SPECIAL ASSISTANCE 

A TIRBHA, provider, or other person qualified to make the determination that determines a person with a Serious Mental Illness {SMIJ is in 

need of Special Assistance, in accordance with ADHSIDBHS Policy and Procedures Section 113, must noh'fy the ADHSIDBHS Office of Human 

Rights within five (5) days of the determination, If the person is not already identified as Special Assistance, notification is required even if 

someone Is involved and assisting the person. 

Part A: Notification (to be completed by the T/RBHA,-provider or other person. qualified arid sent to the Office of Human Rights at 

(602) 364-4590 or via secure e-mail to OHRts@azdhs.gov) 

The following person, who is a person determined to have a Serious Mental Illness (SMI), is in need of Special Assistance. 

-- First NamelMuhammad I Last NamefMuhaymin 

Address f Homeless 

I oosjo I Residence Type ... IH_o_m_e_1e_s_s ______ _..,J 

I City ,...,P_h_o_e-ni_x _____ """'I State !Arizona I Zip code I .... ____ _,I 

Phone ~==---51_0 __ _.I Guardian (If none, list NIA) l,...M_u_s_sa_l_lin_a_M_u_ha_y_m_i_n ________________ .... l 

0Yes 

Title XIX? Q No CIS ID f-0335 

SMI Provider Name I .... T_e_rr_o_s_H_e_a_lt_h ________ _.l 

SMI Case Manager I_K_im_be_r_ly_B_ry_a_n_t _______ _.l 

SMI Clinical Supervisor f .... A_m_y_B_ea_rd ________ ___..l 

TtRBHA ,_lr111_M_1c___ _. GSA (NIA for T/RBHAs) EJ 

Site Name/Location 1 ....w_e_s_t_M_c_o_: o_w_e_u _________ --' 

Site Phone 1602-278-1414 

Site Fax 1602-269-8410 

Indicate the areas of Special Assistance need. Please check all that may app!y, regardless of whether a process is currently pending 

fl) Service Planning Ill Discharge Planning Process ll)Grtevance Process ll)Appeal Process 

Provide the clinical basis to support that the person is in need of Special Assistance. Please detail the specific circumstances and hov1 they affect the person's 

ability to communicate preferences and/or participate effectively in the ISP, discharge planning, grievance/investigation. and/or appeal processes 

Muhammad is new to the clinic and his sister has filed for guardianship prior to Muhammad coming to Terros. She currently has 

temporary guardianship. Muhammad is diagnosed with 295.90 Schizophrenia Undifferentiated Type; he presents as paranoid 

and so far has only engaged when-with his sister. His symptoms of schizophrenia also impair his ability to communicate. For 

example, he uses hand gestures to answer questions. Please note he has a high substance use which substance is unknown 

\ he only identify \Vith marijuana. 

I 

Grievance or O Yes 

Appeal Pending: @ No 

Currently Qves 

Inpatient? @No Inpatient Facility & Unit' i... __________________ ...,! 

Indicate a guardian. relative, or a friend is regularly involved with the person and Behavioral Health provider. 

If so. by Who (Name} IMussallina Muhaymin I Relationship !Guardian/Sister I 1.--------:::==================1 

Phone~786 I Address 

Is the person in need of Special Assistance aware that you are submitting this notification? © Yes O No 

Please Explain: 

Mussaflina Muhaymin is aware that this form is being submitted on the behalf of Muhammad. Cm called and left message with 

detail of the Special Assistant Form. 

Date Completed 110/26/2016 

Phone Number Jso2-278-1414 

By Name IKimberly Bryant 

I E-mai!jkimberly.bryant@terros.org !Title lease Manager 

age of2""""""""""'===----~:-:::-::::==========::::::::::::::::::_:: __:;::[a=st;:;;R;::evi:;:·s=ed~: 

Effective date: 10/01/2015 

Name: Muhaymin, Muhammad DOB: Date: 10/26/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 60 of 179
COP 015280

ADHS/DBHS Policy Form 113.1 

NOTIFICATION OF PERSON IN NEED OF SP.ECIALASSISTANCE 

!PART B: Response (to be completed by the Office of Human Rights Administration (OHR): lii~~~~l~~:r .•..•. l.li.1.I .•. f.:~ .. 

0

~.·.~·.(. i(i!.if !!]1]1 ! ::i1.!.f 11.l: ,----;:::============= .. = ........ = .... -= ......... = ........ = ......... = ........ = ......... = ........ = ......... =:::::; ............................................................................................................................................................................................................... ":;.." .. •·•..;.;.::.•· ..... · ----'-"'--"-"""-;:::::::::::::::=::::::::::;1 

Re: NAME ______________ __. DOB j I Original Part A Notification Date I .... ____ __.I 

I Per the information provided/supplemental information obtained, the person meets the criteria for Special Assistance @Yes QNo 

1---------------------------------------------- tThe person requires Special Assistance in the following areas 

I 

lZ) Service Planning 0 Discharge Planning 0 Grievance Process [Z] Appeal Process 

The follO\ving person/agency is designated to provide Special Assistance 

0 OHR Assigned Advocate.__ ____________________ _,, Phonel .. _______ .... ! 

Date (as of} ! ________ I 

OTHER I 

First Name !Muhammad I Last Name ... f M_u_h_a_y_m_i_n ______ _.l Relationship I ..____________ I 

Address .. IH_o_m_e_le_s_s ______________ l City !Phoenix I Phone I ... _______ __,( 1 

1

Additional Information, if any: 1,-.. ..................... ._. ....... ___ =-....................................................... ~-= .. -= .................... =="="· ...................... ="""a= ............ ...-""" .. =""""~'Q~--==-...... --=......., .... = ==·=· .. ·-·1 

J....._r======,-----;:::::===:=::;:-----;:=========:::::----;::.====-=-=-=-=-~1 1 

Datef ... ______ I First NamelMuhammad f LastName .... lM_u_h_a_y_m_in ______ --JI OHR Tit!e I .. ______ __,I 

PART C: Notification of Change (to be completed by the T/RBHA, Provider or other person qualified) 

Please indicate the date when the need for Special Assistance was no longer required and the reason(s) why .. Submit Part C to OHR within ten 

(10) days of the detennination .. 

As of, Date I .... ________ __.I 

The above referenced person no longer meets the criteria for Special Assistance for the following reason(s): 

The person was informed, due to a change in circumstances. he/she no longer meets the criteria for Special Assistance and OHR is 

being notified 

Please exolain: 

First NamelMuhammad 

Phone,....2510 

j LastNamelMuhaymin 

I E-mail I ___ ,,,,., _____ ==---==== 

.__ _______ ........................ ___ ............................................. _ ... , ____ .,....Page .. ·2of"..:: 

I 

I 

' 

Agency I 

Title I 

Date Completed 110/26/2016 

-.... 

I 

I 

I 

Last Revised: 

Effective date: 10/01/2015 

Name: Muhaymin, Muhammad DOB: Date: 10/26/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 61 of 179
COP 015281

ADHS/DBHS PofJcy Form 113.1 

. II :i•,,,.~· ;. '""' ~·""rn· -~~~ -~"""'~""~,.,~-··. . ·•,. !,•,• m• ;J 'd,J•· ;1:..• ':.a-ID f~~t.i-H,.J)S'Ut~~~, a~ jt,1,'!ft~~ ~A•~.. ;.;.; .. ~~=:..t.:t•:~~~· 1-:--:;-------------------_...:.-,------------f:§-:Rf!/. ~ K~ · .:.~~~ .. i~ ;~-;;":~~ifs~:~ 

~~~TB: Response. (ta bs completed by the Offlca of .Human Rights Ad~inlstration (OHR}; -~~~lt,~-i~l~j 

NOTIFiCATION OF PERSON iN NEED OF SPECIAL ASSISTANCE 

~~~ NAME. !Muhammad Muhaymir . J oqa· : I Ot1glnal Part A Notification Date [10/27/18 . I ~~i U1e Information provided/supptemen~I Information obtained, ltle penion meets the cr\taria for Special Assistance @Yes QNo 

I ' !l . . . . 

f?r the Clinical Team and emafl dated 11/8/16, Member meets Special Asslstance·crlterla due to Medical-Psych!atrlc Condltlon 

ln,bluding Schizophrenia-and symptoms of paranoia and substance use which also Inhibits his ability to communicate severely t 

impacting his participation in setvice/dlscharge planning and grievance/appeal processes. Sae Part A for more detail, 

The parson requires Special Assistance In tha following area, 

.· @ S2rvice Planning 0 Discharge Planning @ Grievance Process 0 Appeal Process 

The followlng'peraon/agenQy.is designated toprovida Special Assistance 

q~ OHR Assigned Advocate '----------------....------..,.j Phone .._I ______ --11 

°,,te(aSQij ~( _______ .....i·l 

lZll OTHER 

j ! F!rst Name l~ussalllna f Last Name ._[M_u_h_a_ym_·_in _____ ___.l Relatipnshlp is!s!~ __ -=] 

~ j 11 '• Address ~ J City IPhoelifx 85042 I Pnone-786 (eel!) I 

A~ltional Information, If any: 

:· I 

yljpical Team, please regularly involve the above-named person who Is meeting Special Assist~nce needs as delineated in 

~~/loy 113. 

'.i . 

lf 

., :It /) ··, I 

~ OHR 11ue loHR Advocate [I . I ~~r C! Notification of Ch~n9e (to bo comple~d b~ the T/RBHA, Provider or cthef, _~rson qUB.lrfled) 

P.l~~se lnrJ!cate the date Whan the need for Special Assistance wes no longer required and the reason(s) why. Submit Part C to OHR Within ten 

(1 D} days of the datermlnatlon. 

' ~i· , J· Asjbf.Oate[o/ lo 7 Ii~ l] I .,! r r • . · T;h~ above referenced person no longer meets the crlterla for Speclal Assistance for the following reason(s); ;p~°'~ 

~ I, 

rr~ person was Ir.formed, due to a change in clrcumsfances, he/shs no longer meets t,e crtterla for SpocJa! Assistance and OHR rs 

b~(ng notified _ -

P

·- 11r ·. , . ' \>- _l l- - ease Blmll:Un: = ~ . , 

,' 11 

\, !~ 

\ ' ~ ~ 

; ;t 

·ovcs 

@No 

L..;,_. -----.------------------------------•--•----...---'I • 

Aeency I JCr~.s 

Tltfe 

Date Complakld 3' ... 7 -Z d/ 7 It 

'--'--'---------------------p,.,;a""',ge,,...,.2""'01..,.2.---------· 

I I 

L11.sl RBV1&ed. 

Effeetlvo date: t 0/0112016 · 

Name: Muhaymin, Muhammad DOB: 

Name: Muhaymin, Muhammad DOB: 

Date: 01/14/2017 

Date: 03/13/2017 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 62 of 179
COP 015282

~ 

< ~ ~ 

1 

,.L 

3 

4 

7 

10 

11 

12 

13 

z "s 

~: H~ 14 

◄ :8 ·t ~ A.i<i 15 3 e.i~ i 1 IO 16 

~ I? 5 

> 11 

18 

l~ 

20 

~l 

22 

23 

24 

25 

26 

21 

28 

l 

l 

Name: Muhaymin) Muhammad 

(N THE SUPERJOR COURT IN AND FOR THE STATE OF ARIZONA 

IN AND FOR THE COUNTY OF MARICOPA 

In the n1at1er of the of: 

MUHAMMAD A .. MUHA YMlN~ 

An Incapacitated or Protected Person. 

PB20 J 6 .. 003462 

ORDER OF CON'I'rNUANCE 

I 

Upon motion of Counsel for the Ward to continue the hearing set for December t, 2016 at 

3:00 p.mt. 

ff IS ORDERED that this matter is rescheduled for .:Ja-n~ {i_ ·-. ~ 2ofr 

~-,- (J /D: 0 0 L.&.,1'11'. 

IT IS FURTHER ORDERED that Petitioner's Temporary Letters be extended until 

~ 61" J.o/1 and the Clerk is directed to issue new Temporary Letters effective until such 

date~ 

;.......,....._ ___ ,_ ........ -..,....-~ 

IT IS ORDERED watving the fee for a 

certified copy of thia Ord•r of AppOintment 

an-.1 Gift• ~•u.r ot Appo,ntm•~• 

DOB: 

aBianca, Commissioner 

Date: 12/12/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 63 of 179
COP 015283

OR O Respondent 

SUPERIOR COURT OF AR.IZONA 

IN MARICOPA COUNTY 

~he Matter of: (check one or noth) r Guardianship O.-Conservaton;;h ip 

~~~- M\~'4rrtt) 

· an .~du it D a Minor ~ 

Case Number2,0\k>- ~~-,~~L 

LETTERS OF APPOINTMENT 

AS TEMPORARY 

(Check cne box) 

C Guardian and Conservator 

~ Guardian 

0 Conservator 

AND ACCEPTANCE OF TEMPORARY 

APPOINTMENT 

ISSUANCE OF TEMPORARY LETTERS 

1. NAME OF PERSON APPOINTED: This person (name}_~~t._O.. \J\L~"\ ~ r"\ 

>S appointed as: 0 Guardian and Conservator OR¢ Guardian ORO Conservator 

REASON FOR APPOINTMENT: The person 1Nho needs a guardian and/or conserJaior is 

D a minor OR Dan incapacitated adult or a ward oR'fp. a protected person 

4. 

.,,,,.- \ 

LENGTH OF APPOINTMENT: ~ ~ \~ ~-1: :;L_Q_\3;: ~ \ 

RESTRICTIONS that apply to this TEMPORARY appointment, by order of the court: 

.,_IM.JJLJLk'I I I l_iw .. H------

........... ►-• IWF'f 

MICH~.·K a-ANES{ CLERK . . - r-.,.\1'.RKlW, 

Clerk of.the Superior Court ·~·, :,. ,t,· • 

. 

•.tl 

~ 

' ' ' 

©Super~or Court of Arizona in Maricopa County 'P8GCT82. 

············· .,•.·. · ·· · · ., ......... ALL·RlGH·fS· RESERVED·····-·······-···-·-··-··· -···· - · ·················· .... ···· · ..... f?age .. t of.2 ........ . 

LTA . use only .most .cwrentv. . flt..~ .::::-~~~ . -··-····- __ 

. Yl .. · 

I 11 I I 

Ill 1111111 111 DOB: Ill I -r-lll-llll-lll-O -----------------

I I II I I I I I I I ,11. 

Date: 12/12/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 64 of 179
COP 015284

ACCEPTANCE OF TEMPORARY APPOINTMENT 

State of Arizona ) 

Maricopa C ou n!y ) ss. 

I accept lhe duties as TEMPORARY O Guardian and Conserv,;tor OR~ G1Jardizr ORO Conservator 

of M vl Y'!_ff)(CltJL Vt Lt Yl f1¥JtiIB ------ __ ,,,,.,. ______ (nme)' 

! swear that ! vtm oerlcrm these duties according to !aw. 

~~~~'~ (\ \ ~ -·- GUARDIAN ANotoR coNsrnVAToR 

. ... ...... .. . . . .. .. . . . . . . ............... ~.. . . . . . . . ... " . 

©Supericrr Court of Ariz.on.a in Maricopa County 

,.,•R-••••••••--•-<-~•~~~--Abb•RIGHTS•RES6RVED ,,, "• • ............. • ... •• ,w• , •. , 

PBGCT82f 062107 

. Page. 2.ci 2 .. -v-,.· ... -.-.-"-~~,---m .... •·- Use .. oniy most .. current version,, ...... ··-· ....... , . 

LTA 

Name: Muhaymin) Muhammad DOB: Date: 12/12/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 65 of 179
COP 015285

ADHSJDBHS Policy Form 113,1· 

NOTIFICATION OF PERSON IN NEED OF SPECIAL ASSISTANCE 

I ,. .:tttfi,.t~~1~=:~~1;~t,·~,£:.=~lr;!<;1f~g~r\·~l.;~~ift~~t~{~ :!: ~i~t~talliii ,1⁄4, ~?.]~tt~~1~~4t4h~ 

PART 9; Response (to be completed by the Office cf Human Rights Admi11i$tration (OHR): 1~;;w.~1~~iclr~?~,tql!if.l-lr1Jit- ,,. tili8ltl\11t~i~.IJ~·~~r~~~~~~W@~~t 

R~ NAME !Muhammad Muhaymin I DOB 1 I Original Part A Notification Date [~ 0/27/16 I 

' '.} 

P~~ the inforrnat!on provided/supplemental information obtained, the person meats the criteria for Special Assistance E)Yes QNo I 

f~r the Clinical Team and email dated 11/8/16, Member meets Special Assistance criteria due to Medical-Psychiatric Conditfon J 

including Schizophrenia and symptoms of paranoia and substance use which also inhibits his ability to communicate severely 

Impacting his participation in service/discharge planning and grievance/appeal processes, See Part A for more detail. 

Tile person requires Special Assistance in the following areas 

IZJ Service Planning (ZI Discharge Planning 0 Grievance Process 0 Appeal Process 

The following person/agency is designated to provide Special Assistance 

10 OHR Assigned Advocate Phone I 

I I Date (asof) 

,. "

tzl'. OTHER 

f Relationship !sister ' . :: 

First Name IMussaliina I Last Name IMuhaymin r ! ii: 

' :}· 

. =~ 

; !~; Address~. I City !Phoenix 85042 I Phone 786 (cell) I !i. ' ;; . ;• 

Add.itional Information, if any; . 1, . . ,. 

Cllf.lical Team, please regularly involve the above-named person who is meeting Special Assistance needs as delineated in 

Po'.iicy 113. 

:: 

:.: 

;;: 

: H I, • j j 

Oa~e,11/16/16 I First Name Cynthia (\ ,1//1.lv. ~~ ~.Name!Fullen ./ U)ti,AI'-" OHR Title loHR Adv~~te II ... A I 

" ' , . ., :i: .... , ,/ 

P.A'RT C: Notification of Change (to be completed b~ the T/RBHA, Provider or other rlerson qualified) I·. 

P~e indicate the date when the need for Special Assistance was no longer required and the reason(s) why. Submit Part C to OHR within ten 

{1C>) days of the determination. 

: ;~ 

As j~t. Date I I I j 

' if . i The above referenced person no longer meets the criteria for Special Assistance for the following reason(s): 

: !1-

,. : J 

;!-

,. 

' :;. 

: It : j: . 

Tne person was informed, due to a change in circumstances, he/she no longer meets the criteria for Special Assistance and OHR is ()Yes be(ng notified ., @No Pl,ase exclain: 

,·. . " if 

' !} ' !: . ;;• 

:! . 

.. 

I I I First Namel I LastNamel I Aeency 

I Phone f I I :~ J E-mail Title .. I I 

Date Completed 

Page 2 of 2 Lnst Rev!aell: 

Effective date: 1 0/01 /2016 

Name: Muhaymin, Muhammad DOB: Date: 01/14/2017 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 66 of 179
COP 015286

E 

AOfiSlDBHS Policy Fonn 113.1 

NM'iFICA 110N OF PERSON IN NEEi> OF SPECIAi,. ASSISTANCE 

A TIRBHA, provider, or CJ'ther person qusltned to make the determinaUon that d8termimn a person wltb a Serious Mental Illness fSMJJ ts in 

need of Specie/ AssJstanc9, In accordance with ADHS/DBHS Policy and Procedures Sectlon 113, must natffit the AOHSIOSHS 0/mr, of Human 

Right~ wilhin ~ i (5} days ()/ the determination. If the {)6fSOn Is not already identifiltd aB Sper;ial A$~~tanr;a, notffirmtion is ,equirsrt even If 

someon& is involv8rl end easfsfing the person. · I Part A: Notification (to be compfetecl oy tne TIRBHA, providet' or other pereon qualified and sent to e vn1ce OT numan Klghts at l 

(602} 364-4590 or via secure e-mail to OHRts@azdhs.gov) 

' ........... _,.,..,..., .... ---- . i: . ![ 

The rol!owlrig person, who ls a person determined to have a Serious Mental Illness (SMI), is in need of Speo:al Assistance. 

FirstName~uhammad r Last Name IMuhaymin I ooafo · I Residence rype IHom;i°;s I I 

' 

Address !Homeless J City IPhoentx :: :: .. j state !Arizona I Zip coda f 

l 

I I 

I I l 

Phone ~510 I Guardian (If nona, list NIA) f Mussallina Muhaym!n :c firnfeo-<r > :I I 

• ·• G)Yes CISID ~35 I T/RBHA IMMIC I : •• _ Tille XIX? O No GSA (NIA for T/RBHAs) ~ 

ii ;j 

(West 'McDowell 

... I ' $,Ml Provider Name I Terros Health I Site Name/Lcoatlon ,, 

., I 

' ~Ml Casa Manager IKimberiy Bryant I !so2-21a-1414 I ' Site Phone 

: 

iMI Clinical Supervisor JAmy Beard I Site Fax 1602-269-8410 ~I• I 

jr 

;, 

Indicate tile areas of Special As,latanc! need. Please check an that may apply, regardless of whether e process is currently pending ;;: 

ii 

;, 

• :f lZJ Smifi;e Piannini; tZI Oisd1erge ?l&r1nlng Proceas tzjGrlevance Process IZ)Appeal Process 

•• I 

,; l f?rovllie the cllnlcal basis to support that the parson ls In need cf Special Asslatence. ?lease dela!l the specific clrcumstsncea and how they effect the person-a 

ablllly lo comnnmicate prefsnmces end/or pal11clpate effecUvely In the ISP. dlsch.arge planning, grte11ancelinvesti9alfan, sndfor appeal processes 

Muhammad is new to the cUnle and his sister has filed for guardianship prior to Muhammad coming to T&rros, She currently hae 

· temporary guardianship. Muhammad ts diagnosed \'11th 296.90 Schizophrenia Undifferentiated Type; ha presents as paranoid 

iand so far has only engaged when Wllh his sister. His sympto1n&- of .schizophrenia also Impair his ability to communicate. For. 

example, he uses hand ~stures to ansv1er questio11s. Please note he has a high substance use which substance is unknown 

he only identify with marijuana • .. 

.. 

;;. I I I :~Grievance or Q, Yes Currently Oves tipatienl Fac!lity & Unlt :[Appeal Pending: @No Inpatient? G)No . I ,. 

IHdicate s guardian. relative, or a friend is regulariy involved with the person and BehaVioral Health provider. (!)Yes QNo I 

! 

1iso, by Who (Name) IMussamna Muhaymin I Relattonshlp~erdlan/S~ter : l I 

i 

I 

■ I I r 2 • 

+.one llllllijto1as , Addre&s~ I City IPnoenfx I i 

I 

I 

" I .~ . G)YesQNo I 

Je: lhe pmon In need of Spaclal Assistance aware that you are submitting 1hlS notiflcatlon? I 

P.iease El<lllaln: I 

MussaHlna Muhaymfn Is aware that this form is being submitted on the behalf of Muhammaci. Cm called and left message with I 

r 

, #etafl of the Special Assistant Ferm. · 

' • • I 

I ' 

Date Completed f 10/26/2016 I ey Name IKlmberty Bryant I i 

I 

l 

.-~,.......-.-:--

-~ 

._-J 

Phone Number 1ao2-21a-1414 I -mau Jklmberiy.bryant@terros.org Title I 

rae·r-ot 2. , .. ., ...... r Last Rev1,~ : I g I 

effecllve date: 1fJ/G112016 

Name: Muhaymin, Muhammad DOB: Date: 01/14/2017 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 67 of 179
COP 015287

ADHSfDBHS Polley Form 113.1 

- -- - NOTIFICATION OF PERSON lN NEED OF SPECIAL ASSISTANCE 

A T/RBHA, provider, or other person qualified to rnake tha detemi/natfon that dstermin8s a psrson with , Serious Mental I/Inns fSMQ is Jn 

nssd of-Spec/al Asslsten.ca, In accordance with ADHS/DBHS Policy snd Procedures Section 113, must notify the ADHSIDBHS Offir.e of Human ' 

' Rights within five (5) days of ths determination. ff the pef5on ls not already identified&. Sp&r;lal Assistance, notification is roqulrod ovon If ! 

' someone Is Involved and assisting the person. 

fi'art A: Notification (to be completed oy tne , 1RBHA, provider o'r' other perBon qua lined and sent to e v111ce OT riuman lghts at ! 

(602} 364-4590 or via secure e•mall to OHRts~tdh.s.gov) . 

-- I 

The following person, who la a person determined to have a S&rlous Mental Ulness (SMI), is in need of Spec:al Assistance. 

First Namef Muhammad I Last Name lMuhaymin I coelo ] Resicfence Type (Homel;-s J I 

I 

! 

I City (Phoenix 

' 

Address !Homeless I State ~.:_lzona } Zip coce I I. I 

I 

I I 

Phone iiii2s10 J Guardian (It 110110, list NIA) jMussalllna fvluhayrnln: c1e;;;;;,;;;; > I 

('e)Yes CISID 1~0335 I T/RBHA IMtAtC I GSA {NI~ for T/RBHAs) EJ Title XIX? O No ! 

SMI Provider Name ITerros Health (west McDowell I Slte NameJLocatlon 

' : I 

SMI case Manager !Kimberly Bryant I Slte. Phone 1602·278-1414 I 

SMI Clinical Supervisor f Amy Beard 1 Site Fax r 602-269-841 o ::] 

Indicate the areas of Special Assistance need. Please check art that may apply, regardless of whether a process ls currently pending 

l£l Servlce Planning 121 Oblcherge Planning Process ~Grievance Process IZJAppeal Process 

Provide the clinical basis to support that the parson ls In nee:1 of Special Assistance. Please de!a~ the spec11lc clrc\.RTl&tance9 and how they e.ffect the person's 

ablntv to commanlcirt• pn~ferancu and/or participate effecUvc!y In lhe ISP, discharge planl"llng, glfev&l'IC(!finllestigatton. and/or appeal prccesaes 

Muhammad is new to the clinic and his sister has flied for guardianship prior 10 Muhammad coming to T&rros. She currently has 

temporary guardianship. Muhammad is diagnosed with 295.90 Sch{zophrenla Undifferentiated Type; he presents as paranoid 

and so far has only engaged when with hls sister. Hls symptoms of schizophrenia also lrnpalr his ability 10 communicate. For. 

ex.ample. he uses hand gestures to answer questions. Please note he has a high substance use which substance is unkno\vn 

he only identify With marijuana. 

I ] Grievance or QYes Currentty Qves lnpsllsnt Far:ilit.Y & Unit Appeal Pending: © No Inpatient? @No 

I 

QNo 1 

L 

Indicate a guart!ian1 relative, or a friend Is regulany involved With the person and Behavloral Health provider. €}Yes ! 

l 

If so, by VI/ho (Name) IMussamn~ ~uhaym!n I Relatione'.iip§~erdl'an/Sl~ter I ; 

! 

City 'Phoenix I • 

Phonaiiai-o786 

' :] Address (1214 S. 41st Street r 

i 

l 

I 

! 

• 

Is Iha per&on In need of Spacial Asslstance aware that you are subrrlttlng 1hls notification? @YesQNo ! 

I Please Explain: • 

I 

MussaHlna Muhaymln ls aware that thls form Is being submitted on ~e behalf of Muhammad. Cm caned and left message \\4th ; 

• 

datall of the Special Assistant Form. I 

I 

I 

' 

' 

Date Completed 110/26/2016 I By Narne f Klmberly Btyant ] ! 

I ....... .. 

!-mall kimberly.bryant@te;~,org 

9"'.s~ ........... .._ ..... _ .. __ ......... , .. ,., .~,., ... -~--·~ 

' -·· ... -:-::.. ·~ ;=::-= . 

Phone Number !802-278-1414 Title Case Manager ................. -. 

rage 1 or, La&1 RovlmJ: ' 

I 

Effective dat9: 10/01/2015 

Name: Muhaymin, Muhammad DOB: Date: 11/16/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 68 of 179
COP 015288

ADHS/DBHS Polley Form 113,1 

NOTIFICATION OF PERSON lN NEED OF SPECIAL ASSISTANCE 

.......... 

PART B: Response (to be completed by the Offlce of Human Rights 

--· 

Administration {OHR): :!ilJlli■BJ Re: NAME !Muhammad Muhaymin I DOB 1 I Originai Part A NoUficatior. Date [10/27 /16 I 

Per the information provided/supplemental informatlon obtained. the person moots the criteria ror Special Assistance €)Yes QNo 

Per the Clinical Team and email dated 11/8/16, Member meets Special Assistance criteria due to Medical~Psychiatric Condition 

including Schizophrenia and symptoms of paranoia and substance use 'vVhich also inhibits his ability to communicate severely 

impacting his participation in serviceldischarge planning and grievance/appeal processes. See Part A for more detail. 

- The person requires Special Assistance in the fo!lowing areas 

I Service Piannlng [ZI Discharge Planning [ZJ Grievance Process 0 Appeal Process 

The following person/agency is designated to provide Spacial Assisiance 

D OHR Assioned Advocate Phone I l ~ 

Date (as of) I I 

0 OTHER ! 

! 

First Name IMussalllna I Last Name IMuhaymin I Relationship !sister I 

Address ,........ ! City !Phoenix 85C42 I ?hone -0786 {ceH) 

Additional Information, if any: 

Clinical Team, please regularly involve the above-named person who is meeting Special Assistance needs as delineated in 

Policy 113. 

/) , ) / 

:::--

Date{ 11/161"16 I i, Al~~ 

# I OHR Advocate II l First Name Cynthia Name Fullen / v_/tt-' OHR Title ~ . / , ., 

PART C: Notlftcatlon of Change (to be completed b) the T/RBHA, Provider or othe{derson qualifled} 

Please indicate the date when the need for Special Assistance was no longer required and the reason{s) why. Submlt Part C to OHR within ten 

{10} days of the determlnation. 

As of; Oate f l I 

The above referenced person no longer meets the criterla for Special Asslstance for the following reason(s}: ! 

The person was informed1 due to a change in circumstances, he/she no longer meets the criteria for Special Assistance and OHR is Oves I 

being notified I .,. 

0No I 

Please exolain: I 

I 

I 

I 

""""" 

First Namel I Last Name\ I Agency I I 

Phone I I I J I E-mail Tltle I 

Date Completed I I 

e 2 cf 2 -· Last Revloe:l: t'8 g 

Effective date: 10/01/2015 

Name: Muhaymin, Muhammad DOB: Date: 11/16/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 69 of 179
COP 015289

t"'""~---ot,............__,v+pc L alE ..... _.II 1r-.,.,"-;••.-._,,;.,I.'• • 

I j 

I 

Piilrson f ltlng:_. --,-,~-~...--~__,.~~~~~-......... 

A.ddrasa (If not protac.te ~·~ ..... ~r--.11111(-+-~~~_;,_---

j 

! l li AUG 23 PH ~: 45 Clty ~ Stat&} Zip Code:~~~i.....:.....t~-~.._....-....-+,._ ___ _ 1 

Telephorts~---~.....,......:...-.:---~~~~.,.__ ___ ___... __ _ 

Em.an Ad-dmss.:, _ _..__--..:..s.J11~r-ti1111""11J.Ju...a..~. ~~WL...f...~"-J.....i.... ! CERTIFIED COPY . Lawyer's Bar Numti(!r: _____ ~··-·-· ----------· _ I FOR CLfR1....;'~, tJ::.E OrH. ', 

Licensed Fiduciaiy Numbet~ ----•~-•w ____ , _, --~-·-· __ .,,.,._,_, ___ --· • ..- .... 

I 

t - - . .... . --· ~ . ,.-~ .. -·-~ .,.,,..._ u •. ,_ . 

Rapn,senting O Setfl wlthout a Lawyer or D Attorney fot D Petitioner OR O R!spondont 

SUPERIOR COURT OF ARIZONA 

IN MARICOPA COUNTY 

In the Matter of: (~.;,eek one or both) 

¥Guardianship O Conseivatorship 

Case Nurr.ber:_f.f?_2~1 ~-=- QoS~ lR z_ 

Ler1e:Rs OF APPOINTMENT 

D a ~1inor 

.. 

AS TEMPORARY 

(Check one box) .. 

D Guardian and Conservator 

ii:]"'Guardlan 

0 Conservator 

ANO ACCEPTANCE OF TEMPORARY 

APPOINTMENT 

ISSUANC.E OF TEMPORARY LETTERS 

2. 

NAME OF PERSON APP01NTED: This person (nameL,1~J.l~~-,,pu..b&!:j iM.,i_(\... 

is appointed as: D Guardian and Conservator OR~uardlan OR O .eons.a~ tof 

~~.:~~~o-1u°~~~--~N~/O~ ~~Ns:~V~T~R: 

REASON FOR APPOINTMENT: The person who needs a guar.dfan and/or conserva1or is 

D a minor OR 8]a11 incapacitated adult or a ¥Verd OR D a protected person 

LENGTH OF APPOINTMENT:,.,·~~~-l t Z:OLU _ -' '.. , . RESTRICTIONS that apply to thts TEMPORARY appointmentl by order of the court 

.••-t11c••tzr'; ·--~ "11F:P: 

1 _ .al¥11 1"111=M I I Im: ~t-1 --,..., r • p w..--1111. J 1M: 

MlCftAf!L··~Jr;ANES1Cl.ERK 

WITNESS~---__ AU_G_l_3_2_01_6 _ _..,_ . ' 

Clerk pf tha ·superior Court 

' ' . All Rt-GHTS RESERVED Page 1 of 2 IJsa ·only most curren , 

LTA 

I 111 I I I I I I I 

.J. 

Name: Muhaymin, Muhamm~d · · II I I 1

1

J I 1111 11 -----------------------

111111 11 I 

DOB: Date: 11/16/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 70 of 179
COP 015290

Case No. -----

ACCEPTANCE OF TEMPORARY APPOINTMENT 

State of Arizona } 

~Aancopa County ) ss, 

I accept lhe duties as TEMPORARY O Guardian and Conservator OR ~Guardian OR D Conservator 

of .1'{\~Q.;tn,. ~ cl,. .k_ · · . ~(name). 

J swear that l wiH perf hese duties acco 

~UG 2 8 2016 S ubscdbed and sworn to before me this date: ---------

My Comm)ssion Expkes: - .. ·---·~----- c. 

LTA 

I I I I I 1111 I I I 11 I I I 

Name: Muhaymin) Muhammad 11 I I I I I I 11111 111 111 11 

DOB: Date: 11/16/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 71 of 179
COP 015291

SMI EVALUATION REQUEST FORM 

Re< uil·ed l?.eft•rral lnformation 

RBHA: 1"I~tcy.:~Jari¢0,pi(l1itegf~f~ 

* *Plensc ndd rcss all a 

Referral day: 9/16/2016 

l.icnble fields cverv time*•, 

------ Referral time: 1356 

Evaluation Type: 8;o,uti'.ti¢ Pre-SMl: Yes ; · coE1co·r: No'.)••.,;:/: 1--------··--------'------.---- 1--- BHR Name (.I\.KA); Muhammad Muhaymln DOB: SSN: 

BHR Phone #: G Gender: f efu1tJ" Race: White 

Primary language: English Interpreter language: None 

Tl9: Yes··••· AHCCCS ID: 335 

Legal Guardian: \'.'~~T):; ! Guardian Name & nu1nber (legal guardianship 

' tile time of evaluation : Mussallina Muha mi 

Referral source (name and#): Guardian Mussallina Muhaymin Bl-IR agrees to eval: \'c~•-(i :'. 

678-920-0786 

BHR location (please include hospital, unit, room#, etc): 

Booking/DOC# (if applicable): Court Date / Release Date: 

_____ ...... , ____ _ 

uired at 

0786 

·---1 

BHR Address (residential or mailing): Malling HOENIX, AZ 85041 

f.comments: Found SMI 12/14/2010 Dr Hoffman. Per MMIC this BHR never engaged in servs. CIS: 

I 099, MMIC: S03048910 L----··---------·--------------------------' 

Evaluation lnibrmation {l•or CPR use onlv): 

I Evaluator Name: Tamara LaMontaane Detennination outcome: :P rc JSMt .. i,; .i. .•.•.•. 

'""""""""' 

... ,~-"""' 

Evaluation Date: 9/16/2016 Evaluation Time: 11:30AM 

-· BHR site preference: Terros: w. McDowell I Reason for site selection: ( 11 .. ., .. ;;. ·• 11·· ''l'Lf, •'ti , iCO~llP. 1ca ·' .. ·)Ca ._• .. l!O.. • .. .,, .................. ,, •..• 

Eligibility Documents: Tl9. , .. ~,: ..... Days ofM'edications Nhtcu•:telltl \'ta.kiri . ........... , ...... .... , .. ,,,..:t ............ .. g I remainin,z: 

""" 

ls the BHR homeless? ~~$:,r.o.n. ftb.c:;t;fft{ct) ACl' Appropriate: Y.isI}}- ... , .... 

Comments (Serious ' N/A 

Crimes, Languages, 

Special needs, other): .-................... 

.. 

Determination date: Determination {~(b\.it:.$itecte!l) 

I SMI diagnosis (if 

outcome: . 

Site assignment: 

I applicable): I .. - """"""' 

I SMl Processor I 

l l Comments: 

-ii}§•' iiiib~t tb!n!iii• iiiiii!'tiill lliiiiif t iii: riiiiillmriiiiiEiiiiit • iiii:iiiiiiiil: ·idJ· >!liii!lt iAfe&iii:?i&i·teMi•niiia iiii'•iii·miii• iiiiiSiriiiiiiif? iii·R~Fiit''iiiiili7JZ·ii!""-~--:isi-~m t ' ~ r · ft ES rs: jf: • a· t · --~ r 1 &+ t ·Bib UtEii'r •w; fi21:. 

Revised 'l 2-15~ 15 

Name: Muhaymin, Muhammad DOB: Date: 11/16/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 72 of 179
COP 015292

ADHSlt>SH$ Policy Form 1"13.1 

NOlfACA TION OF PERSON IN NEED Of SPiCtAL ASSISTANCE 

A i/RBHA, provider, or other pemon qualified ta make lhs determination thotdetermin11s o per~n with@ Serious Mental lllnpss t§MIJ ls In 

need of Special Assistance, in accorclance with ADHS/DBHS Poocy end Procedures Section 113, must notify the ADHSIDBHS Offlc9 of Huma11 

l«ghts within nvf) (5) days of tho determination. II the person is not already identi!fBd as Special A~slstanr;e, notifir;afioo i1> roquirod oven if 

someon& is Jnvoht6d and assfstlng the psrson. · 

Part A: Nctfification (to be completed by TIRBHA, provide.-or other peraon qualified and ~n tD e uman Rights at 

(602} 364-459D or via se-eure e-mail to OHRts@azdhs.gov) 

The following person, who fs a person detenn1ned to have a Serious Mental Illness (SNJI), is in need of Special A$sistancs. 

Address f ttomaless 

Fist NamelMuhammad I Last Name [~:uh~rt1,i,n,, : I DOB f I Residence Type fHomeless I 

.----!=::-----=--=-=-=-=-1, 

I C~ty ~hoenix I State I Ariton a j Zip oooa .._I __ __.I, 

_2s_1_0 _ __, Gua,dian (If none, list NIA) IMussalfina M~aymin :c~fim,perc«y ) I 

Title XIX? O © Yes No c1s 10 335 · _ ' ·: _ l _ TIRBHA _IM_M_lc _ ____ l . GSA {NIA for TIRBHAs) E._J ~ 

SMI Provider Name ... lli_e_rr_os_H_e_a_lt_h ________ lsrte Name11.ccauon l ... w_e_s_r_M_co_o_w_e11 _________ ~I, 

SMI case Manager ... (~_,1m_ber_1_y _B_rv_an_t _______ lSite Phone 1602-278-1414 I 

SMl Clini0al Supervisor JAmy Beara I Site Fax leo2-2ag.941 o I 7 

Indicate the area& of Special Aooiatance need. Please check an tha1 may apply, regardless of whether a process is currently pending 

IZ] Selvlce Planning (ZJ Plscnerge Plenntng Pn;icess ll)Grlevance Process li]Appeal Process 

Provide 'he dlnlcal basis to support that the person Is in need of Special Assistance. Please de1aR the .specific circumstances and how they af'fec1 the person'& 

sbllily to eomrmmleale preferences am.1/or paJt!cip\\te effedlveiy tn the ISP, dltchaige plaoram. grf&vancelirweatlgal.iOn. ancltor appeal pmcas.ses 

uhammad is new to the cHnic and his sister has ffled for guardianship prior to Muhammad coming to Terros. She currently has 

temporary guardianship, Muhammad ls dlagnoset:i wltl1 295,90 Schizophrenia Undifferentiated Type; he presents as paranoid 

and so far has only engaged when with his si$ter. H1s symptoms of schlzophrenJe also lmpGtlr his ablllt)' 10 communicate. For. 

example, he uses hand gestures to answer questfons. Please note he ha& a high substance use which aub&tance Is unknown 

he only identify with marijuana. 

Grievence or O Yes \ 

Appea! Pending; (!>No 

' 

Currently Oves 

Inpatient? @Mo lnpall8"l Facility & Unit I ... ________________ _ 

lndicate a gt.1ardan1 relative, or a friend Is regularly involved with the person and Behavloral Health provlder. @Yes QNo 

If so, byWho(Name) ~~s~allina Muhaymin ] Relationship{Gl:larcllen/S~ter 

~===---======== 

Phone 788 I Address _______ Cit'{ ... IP_h_oe_n_lx _______ _ 

11 the person In need of Speclal Assistance aware that you are subrnitting this notificatioo? @YesQNo 

Please e laln: 

Mussalina Muhaymln ie aware that this form is being submitted on ~he behalf of Muhammad. cm caned and left message wilh 

etafl of the Special Assistant Form. 

Date Completed (10/26/2016 By Name IKlmberly Bryant 

Phone Number 602-278-1414 1 kimberJy.bryant@terros.org 

age o 

I 

I 

l 

I 

I 

I 

I 

I 

I 

I 

I 

I 

! 

i 

' 

) 

. ! 

: 

Name: Muhaymin, Muhammad DOB: Date: 11/17/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 73 of 179
COP 015293

ADHSIDBHS Policy Form 113.1 

NOTIFICATION OF PERSON IN NEED OF SPECIAL ASSISTANCE 

lt~3⁄41f~~~~&.~}~f~ci'it~l~~~/~~J!z.~ ,.,.,~ .. "·"·.~~,.,~r~,,,,~ ,. . ~,_,,~,,,.,,.,.!\8>-~1•'1,···'· 

PART B: Response (to be completed by the Office of Human Right'S Administration (OHR}: ~it1iall~lrdl1~~:.a11 

Re: NAME !Muhammad Muhaymin I DOB 1 I Original Part A Notification Date 110/27/16 I 

Per the information provided/supplemental information obtained. the person n1eets the criteria for Special Assistance (:)Yes QNo 

Per the Clinical Team and email dated 11/8/16, Member meets Special Assistance criteria due to Medical-Psychiatric Condition 

including Schizophrenia and symptoms of paranoia and substance use which also inhibits his ability to con,municate severely 

impacting his participation in service/discharge planning and grievance/appeal processes. See Part A for more detail. 

The person requires Special Asslstance in the following areas 

IZJ Service Planning 121 Discharge Planning 0 Grlevance Process 0 Appeal Process 

The following person/agency is designated to provide Special Assistance 

□ OHR Assigned Advocate Phone I I 

Date (as of) I I 

0 OTHER 

Flrst Name IMussaltina I I I Last Name IMuhaymin I Relationship !sister 

! 

Address 17214 S. 41 st St. I City f Phoenix 85042 I Phone 786 (oell} 

I 

I 

I 

Additional lnformation, if any! 

CUnfcal Team, please regularly Involve the above-named person who is meeting Special Assistance needs as delineated in 

Policy 113. 

•'\ I J ,.. ) J 

Oatel11/16/16 I First Name Cynttiia [' .ii /ILM "'~~e Fullen ./ ~-I OHR Tltle I OHR Advocate IJ •• I. J l ' , . ., 

PART C: Notlflcatlon of Change (to be completed b) 

r ./ 

the T/RBHA, Provider or other rson qualified) 

Please indicate the date when the need for Spacial Assistance was no longer required and the reason(s) why. Submit Part C to OHR within ten 

(10) days of the d&tennination. 

Asof1 Date f 

• 

I 

The above referenced person no longer meets the criteria for Special Assistance for the following reason(s): 

The person was informed, due to a change in circumstances, he/she no longer meets the criteria for Special Assistance and OHR is 0Yes being not!Hed 

(vNo Please exolain: 

I I First Namel I Last Name I I Agency 

Phone I I I I : :: I E-mail Trtle l 

Date Completed I I 

1"'8 g e i ot .tl: Last RcvlNd: 

Effective date: 10/0112015 

Name: Muhaymin, Muhammad DOB: Date: 11/17/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 74 of 179
COP 015294

i ' . 

1 

2 

3 

5 

7 

8 

9 

10 

11 

12 

18 

19 

20 

22 

23 

24 

26 

27 

28 

Name: Muhaymin) Muhammad 

IN THE SUPERIOR COURT IN AND FOR THE STATE OF ARIZONA 

IN AND FOR THE COUNTY OF MARICOPA .. 

In the n1auer of the of: PB20 I 6-003462. 

• 

MUHAMMAD A. MUHA YMIN, ORDER OF CONTINUANCE 

An IncapaciUt.ted or Protected Person~ 

Upon motion of Counsel tbr !he Ward to continue the hearing set for December }. 2016 at 

J;OO p.m., 

IT IS ORDERED that this matter is rescheduled for ;J/J,nfJAK'V -~ , 20 I~ ~,---crJD:0/j 

lT IS FURTHER ORDERED that Petitioner's Temporary Letters be extended until 

~ ?.!., ~l~a.nd the Clerk is directed to issue new Temporary Letters effective until such 

date, 

Entered this J..Jr: day of._ . ...c/Jbv :._ ___ . ~ -..1'~~~ -vvfb-. 

IT IS ORDERED wstvtng the fee for s 

oettlflad copy or thia · Order of Appointment 

anti ~m,· L.t1Hl1f of -"flflttJAlffl@IU 

DOB: 

i 

Date: 11/28/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 75 of 179
COP 015295

I i ' 

I 

! 

i 

l 

Pers on Filln9:~~~~~ -.a,..._._,,a,,:-_..,...;'"'~~~,.,-.iilt~--

Address (ff not p_r~:o.oma ·-...r1_.-..,.)""'""~rws.y..........t+-;a.__...,,p~-~-

Clty1 StaJe, Zt .. C9d~1w_. ~-~~~~~~~~~.u.::,...{_ 

1elephone! , , ·.. · · .. - .. · · 

Email Addre,st . ~\..\$£~ 

LaW)'tt'e Bar ~mber~~ I ,_ .,.,. ,_,. 4 ¥ :1111u•:1110,1111 Iii I -~ 

Licensed Fiduciary Number:-----~-~--- fl' ... ,..,..~ ,-c,------, .... -;~ .... -~ ...... ~ • . ............. ' - . -

Ftapreaentl~g r/J.s.n, without a Lawyer or O Attcirney for O Pet(t!OMr OR D Respondent - I 

SUPERIOR COURT OF ARIZONA 

IN MARICOPA COUNTY 

~e Matter of: (check one or both) · r Guardianship QeonservafOf&hlp 

case Number:1,0~.,:,,~~!l"'2-. 

LETTERS OF APPOINTMENT 

AS TEMPORARY 

(Check one box) 

D Guardian and Conservator 

~ Guardian 

D ConservatorAND ACCEPTANCE OF TEMPORARY . . 

APPOINTMENT . 

> 

' 

j 

j 

ISSUANCE OF TEMPORARY LETTERS ,

1 

1. NAME OF PERSON APPOINTED: Thia person (namet~1.$~ ~~!'\ '. 

is appointed as: D Guardlan and Conservator OR ¢Guardian ORO Cooservalor 

.~~~-,0~--.~~=:IA=~~-~~: 

REASON FOR APPOINTMENT: The person who needs a guardian and/or conservator is 

D a minor OR Dan lncapacilaled adult or ~ward OR)d a protected person 

LENGTH OF APPOINTMENT: .:J~--. Z,,\;._ ~-~5'.ac"••-••"·'"··· ..... .. \ 

5. RESTRICTIONS that apPJy to this TEMPORARY appoinlmenlt by order of lhe court 

* p,1apo1 v ...... •*P IPfl F Rlf • I iilllllilSl<I Ill 1 •;;Jhl $)164,illlstzzlllil!III" RJPFF * ..-iw11 tr....._ .MJlMl ll 41W tlltltl I h 41 -W L-W.ii. 

... ,.: J F: 

Ml~ KJ&ANES~ eLERK • • ... • 1 

Clark ot~tt1e Supertor 'C~urt _ ... ~ .... - ~ ,' " . •: " ' ..... ~ ~ 

w . DEC 18 2016 ITNESS,: __ .. ,. ,_ ---~~~-.. ~ ... . - •Hali T 

. Bu· .. , .. ~--~~-..;.-~~~--IN-f-mt+-~ Deputy_ ♦ i 

~- ~ I .' 

1 · @Superior Court of Arizona fn Maricopa County -. "PBG 

! ---•,---~--~. Al:lt-~rGt«~RESERVEB--------~~~--............._.pag$..;.of ... 2.-----:_ ~t,-se~-~~t:.tJ ·mm.~~ 

! ~~10--

1 LTA - ' 

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I I -~~~~l=O =•=•=II==• l==l l=O =•=•=• =• ------------------------------------------- 111 I I I I I l I I I I I I l 11 I I f I I I I l I I 

Name: Muhaymin) Muhammad DOB: Date: 11/28/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 76 of 179
COP 015296

j 

I 

I 

' 

case No. _ 

_ *_,....,,..._,....__•-• --• d _ _..., 

ACCEPTANCE OF TEMPORARY APPOINTMENT 

State of Arizona } 

Maricopa County ) ss. 

I accept the duties as TEMPORARY D Guardian and Conservator OR f1., Guardian ORO Conseivator 

of -~~oomml. tvtt~htty.m.DI. __ •• u• (name), 

l swear 'that I wHt perform these f)uties accordfng t 

-~ ~~~ . "'""" l {\ I --

.. ~~~~,;,,,4-------

GUARDfAN AND/OR CONSERVATO 

Subscribed and sv,orn to before me this date: DEC l 3 20f6 

MICHAeL KJEANES. CU=Rt\ 

My Comrnlssion Expire~: _______ _ 

©Superior Court of Arizona in Maricopa County PBGCT82f 082107 

-----Abl?R0lM+$:~&.S&RWtl-•---- ~--_,Rage.2..t1£.2 _____ ...._U®_QrnyJI1~ currgnt version 

LTA 

Name: Muhaymin) Muhammad DOB: Date: 11/28/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 77 of 179
COP 015297

.. 

GUIDELINES FOR 

HEAL TH PROFESSIONAL'S REPORT 

INSTRUCTIONS TO PETITIONER; Fill in the information below and give this document to the physicianl 

registered nurse, or psychologist appointed by the Court to evaluate the health of the person said to need protection 

immediatefy after the aORDER APPO[NTING (Attorney, Health Professjonal, and Court lnvestigator)H is signed. 

The complete written report should be given ;o everyone Hsted in the ttORDER APPOINTING1

' no rater than 10 

· days before the scheduled hearing. 

COURT CASE NUMBER: PB I 

NAME OF EVALUATOR: 

' EVALUATOR'S PROFESSION: MPhysician D Registered Nurse Psychologist 

~AM~ OF PATIENT {subject of this evaluation): ___ u...s.L..-,u~6 ........ i!t.i.......a.;;:.r~~4d ...... 4 .... = _d_...;_k....:......;;u;;;..;.......;;/2.&...1:~::;_z;;i:~'4.-/...._4.....,,,.__r ------

(Person said to needguardfan) 

NAME OF PETITIONER: 

PETITIONER'S TELEPHONE NUMBER; 

DATE AND TIME OF COURT HEARING: 

:~·,IN$T~9q!IQ;N_S TO:: ~liYS.l~l~N,: qR·=:-O~ttER ~_VAl;_~!\_T_OR :'.:: l~, ·9~μ_rt_-_c::as:e~i~~a~. b.~=,r.tf~~~d. th_a;t_ ~~~J~~ -:~llμrt :t~( ::app<>"i_nl:a:~g· .,.ardia_n:fQ'r,.Jtl'~:pe~9-_rf_~am~d:as·:~~Pati_er1t~•--a~ove·/: Before:g_rant,ng_sucti.~::p·~ti~i_on:lit~e:~our.f~u~t; i'tle~t-;.id.e<if .r,t1eri~fi-_: phy$h;al~:_:_tlf other:..~-~us~-:e~i~l~::whictr.·~qliir~_!lt·a·p-pointn,~'Qt:9{:a::'.;t1·~~-rdiari/::_r~.'ma_~~fJfi~t- :~f :~11t~f ;k;:nh:~~1~ti;;~;~9

t~ti;t;;;~~it:;~rt:2:A( ,,:-:~;;;_;:,::'.-Yt:::)d/-//))/1':II'.:j;'.)}\I:l~'.tl:~Jz;ii]{; ;:~I1~;::;r:1ri\},jtl;i;~ 

-•: -:••-;:ti!=.; ;,_w_ht?ttier_t _ .~- p_frsq_11 ;nee_d~-~,~P~~,•~0J~,m~r1.tal __ h_~_a,th tre.~tme.nt, .. an __ ,_:·<r= .:-, . .-.••' -:·-:-:,_- ,_:.;._ -,.-:·.'·;'.-:-->:<·.''.•--- =:::~:.' =>:\\.·' ;,:_/,>--'--' 

·,_=ptoyig¢._q_Jofoo. t.t...Js form;·:~r.~te·_:th~t:i·f th~·:_Pe.titi9.ft~r:J~_-see~i,~g._ aμthci~ity to···:tQ,ri••:i~ttQ_JflP~ti~n_tf!le,Qtc}l_-~:,a,;tl:_ 

/Atte/=~v<>:u:.::p·~--~ p~et~~::t"ne ie.:por1;:;giv~·Jh)e'.(qi,,g-in;ai:"°fepo'it;-to·:=,~·e·:.-PeffJ;Q_n~ri Jv.h~::·_•s:·:'r~~i,o_~~i,~i~: ro,r_=:~ist·r.1t>iitl,tg·=;i ::co'p_f e~'_.:~o,'_t11·e.: ·prqper ~ pqrt1.es:~i~:i.:,P.f ~as~;·:ti~~-,,9p~ ·fil~ ·yc,u_r iepor:t· witll_ :Jh~.:~_~er~:-_.of._ -~lje~. g()·~.11~:: ·><:--·::~:' :-_:/;~-r\~_._:·/·:~.:-;:{ ;/'.:t -_::~J:: , __ 

-;' ,-::_•.\•i·'./\•••r.tsr'$~~~J?A~Dt~i:.t~g:~;~~l:it~~o~::T:~~~(tim~t,•."f ~<l>!'{S-:,,,f ,,;.:\•·· 

Name: Muhaymin) Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 78 of 179
COP 015298

Case No. ------·-· -------1111 .. 

QUESTIONS FOR HEAL TH PROFESSIONAL TO ANSWER: 

-------""'""'"'""'"""""''"""""""""""''"'~...,...,..,..,.,,,.., .. v.._, ________________________ _ 

Note: If not enough space on this form to .answer~ write fn ~

1

See attached{; and respond on_ separate page. 

· Please re~state the question on the attachment and·use same number.as-from this document.· · · · I • ~ • 

·t 

j u#sdc 4hllla _...,.. .... l ... lorfWI 1111111 I 1111 I I 11•1 ......................... ,.,..,,,..,.,,,.,.,.,. .............. ,11,.,,,..,.,,..,.,,. ........ ............,.., ___________ -+ ______ fr_rlt __________ _ 

1. 

2. 

What is the date you last saw the patient? 

• How Jong have you been treating the patient? 

3. Why were you asked to do this evaluation? 

[1r J have been the person's physician for many years~ 

[E I was asked to do so by the family, 

D I was selected by an attorney~ 

D My office is close to the person's residence~ 

D I am a O doctort D registered nurse, or D psychologist, for the person's nursing home. 

4. 

7. 

0 Other. 

--------~-------------------

____ , __________ ,..,.,...._...__~--------------------------------,,--..----------

-What is your area of specialty? ........ P....G->'--'~'4---:dd..llf,,,,IL,d,I~'--=·· A--'--7."-11- 4~----,,rc-----------------

Are you Board Certified in this areaii:.J Yes ctfNo 

In a.ny other areas? D Yes D,No 

ff uyes" 1 list: 

_ Does the person you are evaluating appear to be having difficulty in any of the following areas? 

r6 

□ 

□ 

Mental disorder 

Chronic intoxication or drug use 

Anything. else ( explain below) 

D 

□ 

□ 

Physical illness 

Cognitive abilities 

Physical illness ONLY 

If he or she is having difficulty, please specify the nature of the illness. disorder, etc.j 

including diagnosis: 

~it r't x Q"'l- Su Fl<fA-.S: f::. KdJfli S:o£A I ?AP ti4.,.,,PA-,1)~:'f,,,A_ lw ~ - - ~ I 

cl.1.;;;, tlJ. a p # N.J..2-ed Y71f '.'f- ---------------------------------------

------------V.V,Ylff'NoTllla'lll ........ <'!ff'M,V.'Nl!'IIIIIIIIIOIIIIIIIIIIIIIIIIIOIIIIIIIIIIIIIIIIUllllllllllftlllllOIIIIIIIIIIIIIIIIUllllftlllllllllllOIIIIIIIIIIIIIIIIUIIIIIIIIIIIIIIIIIOIIIIIIIIIIIIIIIIUIIIIIIIIIIIIIIIIUIIHIIIIIIUIIIIUlllllllll~V.'\hY-N>'NJ{,'N-"IIIUllllllllllllll•l1tlllll1IIIIOllllll1IIIIUIIIIOlllllltlllll1IW/.?llU.V.V.V.'W,MM'WU.V.YN,'WoV. 

Has the person been treated or hospitalized before for this difficulty? Yes No 

If yes. when and where? \ 

Ue /4 ·A? 6£ r: o YtLP:.4 r~ £ w, u, H e:4, A ZLd ;../Jl UI 11: {q__, 

/i.1c -J"lr:ltrLName: Muhaymin) Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 79 of 179
COP 015299

Case No. --~------

8. is the person able to do the following things? Please check each applicable box. 

D Pay his or her bills O Take medication appropriately 

9. 

10. 

. 0 Obtain food D Provide adequate housing 

. D Live alone D Exercise daily self-h~lp skflls 

· D Make appropriate judgments that will protect him or her personallyr physically, or financially 

0 Drive a motor vehicle. {ff nyes'1 , expla}n below,) 

If you believe a guardianship is warranted but you believe the person to be protected is capable of 

and should be permitted to drive a motor vehicle. please explain .. 

-----------~••'""""""""..,.,, ______ _ 

----~--------------------""'"'"""'"'''"" .................. ------- ---~-------------~-~-------------------

. Do you believe that the medication is affecting the personts ability to respond coherently? _ _/ 

Oves [0No 

Do you believe that the medication is affecting the person's ability to ambulate? D Yes 

12. Do you believe that a i'medication hoUday/1 if possibJe, would help you better evaluate the ~on? 

D Yes LufNo 

13. Do you believe that any changes made in the type or amount of drugs the person iS receivi n.9... would 

noticeably affect his or her mental or physical abilities? D Yes U No 

Do you believe that any further medical evaluation or treatment would benefit the person?,_/ 

_ Yes LJANo 

ff so. please give your recommendation: . 

---------·""""""'"'"'"''"' .............. ----------------- -----------

'-~-""""""""""""' .. , ________ _ 

15. Do you th i~e person would benefit from other types of therapy such as counseling? 

D Yes Li1 No If yes, describe: 

----------""'"""'""""""~ --------------------------

© Superror Court of Arizona in Maricopa County PBGCA 15f-080816 

. ALL R!GHTS RESERVED _ ~age 3_ of 6 _ · _ _ ~ ,,,--:""."--"'\'" .. 4..'cl""'i.',::,,,,wqd'!,>,t,-M•.=--->"S ____ ,...,,~ ~~~~.....;:;:.:::~~~~~~~~~.:.:u:trn:_~';'~>ll;l-:t&~t;~i:kt~~·-!!c.....L"'":":"t"eTIN%''1'1i;,~~~~..,...~-:: -~~~~~~~ -~~~~ 

Name: Muhaymin) Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 80 of 179
COP 015300

16. 

17. 

18. 

19. 

Case No. ---------

Where do you think the person should live today? 

g 

□ □ 

At home with a companion 

In a group home 

in a supervisory care facility 

In a hospital 

□ □ 

□ 

At home with a nurse 

In a boarding home 

rn a nursing home 

In an Inpatient Psychiatric FacUity for inpatient mental health treatment. Explain. 

Other~~ please explain~ 

•---• II -1111-1111-1111-IIMI-IWWW-lll&M---➔----..-----------------------~-----....,._,.----

Do you believe that the person's condition could improve within 6 months to a year? l"'"",:'1 / 

D Yes LI"'No 

Is there is any reason for the court to review this matter again within less than one year?_/ 

Oves ~No 

Please make any additional comments or suggestions you think would be helpful to the court in 

making this decisiona 

t t 

... /'14 ';f:. l (;;Li L , l~. , e .i!. 1::;l:!,.--2,.Jd.!-.o/--· ~~~i_cj!L_ 

, '41P 44JAiJ'. h ,. - · - Mt< e fH4._fJ. _ ... !Lt ·rt 6 ·r. .. _J_!j__e~ I $rl a A2 ~ . 

""""'''"""'""""''""''"""""''""''""""~-.. ---·-----~--~-----------------------

MENTAL HEALTH TREATMENT ISSUES (This section must be completed !Ethe petitioner is 

requesting authority for a guardian to consent to in patient mental hea Ith treatment, and if so~ th is report or a 

separate report covering this information must be completed and signed by a licensed psychologist or 

psychiatrist) 

r-----------------~----·-""'""'"'''---------------,-.-,-_-,-, --------

. ~Jt~: Jin~t ~~bJgt, :s;;;ce ~n this for~ t~

0 

anS~er, wr;te In .. 5ee atta~h~~>~fld ~espond~n i~Paf 8t~:p~-~it : • 

· .· .· ./.··/:Please r~ .. ~fate(_th~e. q1:1estion ~n-the attachment ah~ use sarne·num.ber as from .thirtd_ocunient_.:;::-:·i<:?\'-';::_.-:: ' ·, _.·· ~ ·.t .. :'·) _.::, ·, . .:-"_-:, ··-: .. ·(,I:,_::._>_;·: ":- · > :,' ,:,t· i '.. ·· : ·: . . >,·. : .'::· .. · '.: . :· : ·.,·.,: . · -·: :. '--:_, . : .. ··,.·, . .' · .... ' -: . _·. :- -... · :::.:'.,. ·,. ·:<'.···'··> .. : ·:_. . ·,-~-. ...:_ . \'i _:•i>·: ::·,_..-/-~ ·,~ r ::_.:_<::;';_(\i _·.->: . •' • .. ~• . I;••·.·, . . ,::~ -~-' . ': •• .. :,•~.. •• ~,. 

• • •• ·, • ~ • " ~- .·- .. _ • • ........... _____ • f ------" -- • • " • ~ 

1 .. Is 1t fe opin Ion of the undersigned thatthe patient is incapacitated as a result of a mental disorder? 

@Y~s 0No 

2. What i.s the mental disorder? 

___ 7,..._· &J ,A q; 

© Superior Court of Arizona in Marrcopa County PBGCA 15f~080816 

ALL RIGHTS RESERVED · Page 4 of 6 

~~~~~•~~~-3::'.~1:c a=--:,-...:--:-~'"•~'fC-•--.i.~"K..,.•~~•:~ .. -....;,._..,;........,_~~~-~~~~?~~.ztt.:..,!n,t~~~"!~~~~~,i";,r.r::-;~':.~~~~1::; 

Name: Muhaymin, Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 81 of 179
COP 015301

3. 

5. 

Case No. --------

Is it the opinion of the undersigned that the p~t Is Ii kefy to need in patient mental he a Ith care and 

treatment within the next year? D Yes Llf No (The maximum term for which authority may be 

granted to pface a patient in an Inpatient Psychiatric FaciHty and treatment is one year. This authority may 

be renewed or extended based on the evaluation and recommendation of a licensed physician or 

psychologist submitted with the annual report of the guardian~ A.R.S. § 14 ... 5312.01(P}) 

In the event that the answer to #3 is uves", please explain the need for, and the anticipat.ed onset 

and duration of the inpatient treatment; ,. 

' ' 

~/J ct 11:,;.~_£_ t0 ,&;., • /ii w e '"t S ti ~ (2 JL f r1· t € t=a.f!d f 

What kind of treatment is the patient currently receiving for this disorder? 

H-~ e .. i::1 t!fl U.DJtV~A.J-r- ··-··r··· - " 

l4f f tV JLJ7H e.v ., W 1 1⁄4 & t; td1 u,rr/ri..t.f: r. /.4 # H td?i/7 ..... .............. ............. .......,,..,..., ...... w,,,,,.. 

6.. Give a comprehensive assessment of any functi9nai impairments of the patient .. 

---hi-:r., 2_,u/C __ fi;_1!;!e.~r ... Jfl 6. {Y..JZJ: ... tc.(u Q:, .L~ e.&!deurLr-1_ u u. t!4/J.if;, 

.Yii! t;&tJ f.{ I G ( 'i'--«J j.J, ,J -f AV 6.l Pis I W@ p,../1; -

. ......,,,..,,.. ___ .... ,,,...,,,,,,,,,,,,,,,,,,,, .. ,,.,_'+'Nr'"' _____ ,, .... .,, ... , ............ ,, ... , ..... ,, ............ _______________________ _ 

7. How and to what extent do these impairments affect the patient's ability to receive or evaluate 

information needed in making or communicating personal and financial decisions? ... 

__ _;;[':f Uj!;!<.-!f u1⁄4f1A1.1J:.J-t eu-:r:.. du e rt1 /'-if r cld,.rrr to 5 y Mf1 n~.r 

9 .. 

What tasks of daily Uving is the patient capable of perfonning without direction or with minimal 

direction? 

---~A~T-ff21L,.wN.v .i.,f.1."l,,,;;1 ___ ~.-.,--.,~w~•~w.w."-•,-,.,~wm-•----~-- ------

-------~------------~--------------------------------

What is the most appropriate rehabilitation plan or care pf an for the patient? .., 

"~Z.~'l,:,::.../4..;._,t.,___,..fi-=L-r....o~'--"'' S.:: ...... ....... L J __ ·A ..... ~;;;...-. --=0_' ~~t-..;;;;,;;,1;.___( --,{ ---------.. --H•-~_,,_,,_,, _,,_, _,,,_, ____ ,.,,,.,,.,.,_,.,.,.,,.~,~~---~ 

·--------------------------

10. What would be the least restrictive living arrangement reasonably availaqle for the patient? / - ' 

Le I V fiV r.; /fl 't' 11 IP fl,, 4 f' (..LJ i H-1 E ... i!!H::1:LI -!t \I 

~"''"''""''''"'"""'''"'"'"'''""'''"'"'"' ------------------------------------------------------------------

© Superior Court of Arizona in Maricopa CoJJnty PBGCA 15f .. Q80816 

ALL RIGHTS RESERVED Page 5 of 6 

~~~~~~~~'":$.~~~~~~~~~,,,...._.,.;_ "~~~~==~~~,.X~~~,:x::.:~-~-4~~~~~~ 

Name: Muhaymin) Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 82 of 179
COP 015302

Case No. ---------

11. Is there any reason why this patient should not personally appear in court? D Yes ~o 

If i'yes1

; 1 please explain. 

hM-'..V-.......,... .... ..v..-...,..........,..,..,..,, ... ,,,,.,,.,,,,., •• ,., ........ ___ ,_,,,,, ......... ,, ....................... _____________ ,. __________________ _ 

12. Please make any addjtional comments or suggestion~ you fee! would be valuable to the court: 

nftl'PIIIIIIIII I I Ill 1111111 ............ ..,..,, ............................ -w ...... , ...... ,, ____ ~----

________ , ........ ,-...'ff'u.•NNNN.W_,,."ll.Yo"h"N~ ..................... ,,,1 _____ ,..,,~ ... ,, .. ,m,t l!Um>•> >I .... + ............... _______________ .., _____ _ 

DATE REPORT PREPARED: 

SIGNATURE 

UlUAM VILLALOBOS fvLD. 

PRINTED NAME, PROFESSIONAL TITLE (MDJ RN, etc,) 

·-- -·-·----------------------- Name: Muhaymin) Muhammad DOB: Date: 12/05/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 83 of 179
COP 015303

,. 

!-' 

f'•-•'-,.,_,_•-••••• ~JO~-d~•••••••••..J•• ......... '- .L • •.._.._. •• 

l 

' 

Lawyer's Bar Number:____ . - ..... ~ .. -------~ 

Licensed Fiduciary Number: ________ ,~---~-----

Representing D Salfj ,vithout a Lawyer or L] Attorney for D Petitioner OR D Respondent 

SUPER.IOR COURT OF ARIZONA 

. IN MARICOPA COUNTY 

In the Matter of {check one or bothJ 

15<· Guardianship O Conservators hip of 

Case Number:_ f}3A:-P,{ {, .. :::JJ.Q?, 4 ti}, 

TEMPORARY ORDER FOR 

(check one·box) 

09uardi~nship and Conservatorshi.p 

~ Guardianship 

D Conservatorship 

NOTICE: This is an frnportant court order that affects your rights. Read this order carefuHy. If you do not 

understand this order1· contact an attorney for legal advice. This appointment is not effective until 11L.etters of 

Appointmenf1 have been issued by the Clerk of the Court .. 

I 3PJF7 ..-μ I O I •-~t:"'lft""'~ I i,; I I 

THE COURT F1NDS: 

1. PETITION FILED. A svi1orn Petitio_n for Temporary Appofntment pf a. Guardian and/or Conservator for the 

person named ~bove vv.as fiied wrth the Court by the Petitioner. 

PERSON TO BE PROTECTED·: The person to be protected by this order: 

0 Is a MINOR whose 1-velfare and best interests require the appointment of a Temporary GUARDIAN 

t.o provide for his or her continuing care and supervfsion; 

D 

□ 

1s -a.MfNOR for ~vhom .. flTemp.orary ·c.ONSERY.ATOR is nacessary·becausi:the or she ha~tmoney 

or property that require·s .m.anag~r,nent or proteiHon or nas or may have bU$.int:sS a.flairs whfch rna,J 

be jeopardized by·his n1i_nori~y. er the minor needs ·funds for his or her education ~nd protection is 

necessary :or desirable to· obtain or provide funds. · 

. . ' . 

Is an ADULT who ls incapacitated due to .physical .and/or mental disabHQiesi that he or she is 

unable to make or commun1cate respcns1ble decisions concerning his or her person and that 

appointment of a Temporary GUARDIAN is ·necessary to provide for his or i,~r c9ntintiing: care and 

supervision. .. 

is an AOUL T for vJhom a Temporary c·o NSERVATOR-is necessa·ry because h.e.-or she.is unable to 

effectively manage or appiy- his or her estate :due to p~ysic~I and/or rnentaf disa.biHlre$1 

confinement or disappe-arancet and that It is ·ne.cessary to_obJain or provide-fundf.rfor the support, 

care, and vvelfare of the person to be protected. and of-those .e~titlecf to·_ his.·or'her support~ 

©Superior Court of Arizona in Maricc•pa County 

ALL RIGHTS RESERVED Page 1 of 3 

PBGCT81f 12171 o 

Use oniy most current version 

ORD 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 84 of 179
COP 015304

Case No. -~----· 

3. NEED FOR PROTECT1ONF There is sufficient evidence to support a finding of incapacity or need for 

protection by the person who is the subject of this order; 

4. PERSON TO SERVE AS GUARDIAN and/or CON8.gRVATOR: '\rt ;, h • . · lhuhc:,, r11i is 

competent to serve as: D Guardfa·n·a·nd Conservator OR [8~~Jardfan OR D Cons~~ator. 

5. There fs no guardian or conservator appointed by a court to datel or this order replaces such other order~ 

□ 

7. □ 

EfvlERGENCY .. An emergency exists and there is need under law for the Court to enter this order 

1m1nediatefy; 

PRIO.R NOTICE~ Prior nqtice ·of this order is not required to be given to the person to be 

protected or his or her attorney or others entit!ed to prior notice because aH the conditions of 

Arizona law, ARS §14-5310 and/or 14~5401.01 have been met 

MORE THAN· 30 DAYS. For good causef this tempo~ary appo!ntment may be for tnore than 30 

days, according_ to Arizona law, A.R. S~ § 14-531 O {D) and or 14-5401 , 01 (D} for the foHowing 

reasons: 

111Tlrrrr ........ ...__-fll"l-11 ------. .. -.•----

THE COURT ORDERS: 

1. APPOINTMENT: n'.\115..,:;jfJ.l/.!iM, .~ll)\t• r · is appointed as TEMPORARY 

D Guardian and Conservatoc OR 1~YGuardla. OR D Conservator of th.e above-named person pursuant 

to Arizona law ARS §14-5310·ar1d/6r 14-5401.01. 

2. 

3 .. 

LETTERS: This Order shaH be filed with the Clerk of the Court, and upon fmng a bondf rr required~ 

TEMPORARY LETTERS shaH be rssued to the Appointee in accordance with the terms of this Order and. 

subject to the foUowing restrictions (if any): ____________________ _ 

NOTICE: The appointee shaH give notice to the minor and his or her parents or 1o the 

protected or incapacitated .pefspn named in the caption abover and_ to all othersi 

with a copy of each of the foUowing documents: 

a. The Petition for Temporary Appointment w1th this Order; 

b. The Petition for Permanent Appo~ntment; 

c. An reports~ affidavitst or other documents filed in support of both PetiUons, 

4~ EMERGENCY HEARING WITHOUT NOTICE: 

D Personal s~rv1ce shall be completed no later than 72 hours after the date of thJS order upon the 

perspn who needs the protect1on~ his or her attorney. and the parents of that person if the person is 

a rninor. 

@Superior Court of Arizona in lvlarir.,opa County 

ALL RIGHTS RESERVED Page 2 of 3 

PBGCT81f 121710 

Use only most current versfc,n 

ORD 

111 I I 1111 1111 11111 -1--111-1 1-11 -Ill ___________________ _

DOB: Date: 10/25/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 85 of 179
COP 015305

. t 

' } 

i 

; 

t 

-----·---------~-~--------

case No. --------

PROOF OF NOTICE~ Proof o-f Notice of Heartng shaH be fifed ith the Clerk of the Courtl 

Probate Regrstrar1 as required by Arizona Lawt ARS §§ 14 ... 5310 (B) and/or 14-5401.01(8). 

6~ THE APPOINTMENT ENDS~ 

7,. 

8. 

The Ap~intrnent ends on . · "'_,,. 1 , 20 J b, or 

~ / t3,( For good cause, this temporary appointment has been extended beyond 30 days. 

11 Jiljlllllft'l""''''lt 1lM',.lllfff 2--WWhl i - ,_ ..,._ d_.__,, mmtitt,&WoL 

CHANGE OF ADDRESS~ The person appointed as guardian and/or conservator shaH notify this Court 

immediately of any change in his or her address or the person protected by this order. The appointee shatl 

be respons'fble for aH co~ts resulting from his/her faHure to do soT 

ND: 

No Bond is required, OR 

The Guardian and/or Conser ator shall fiJe a bond in the amount of $ -------------- with the Clerk of the Court, Probate Registrar. 

DONE lN OPEN COURT~ 

©Superior Court of Arizona in Martcopa County 

ALL RIGHTS RESERVED Page 3 of3 

P8GCT81f 121710 

Use only rr1i:.'St current version 

ORD 

I 11 I I 

11 J 1111111 111 111 I 

DOB: I I I I ,I lo 

Date: 10/25/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 86 of 179
COP 015306

.. -- - -- ----- -- ----- ------- ----- ------ . - ·----------------

r

·- ......... '>" .,.,.__ ... j ..,,.,.." .. ..,.,. ....... ,.,_.... .v_. ...... ,,, ........... ~..._...... . .......... ~....,,_ .. ,, .. , ......... ~-""'r-·M, ... , •.. ..,. .• ,,,,..,.,.. •• VM1V.• ......... v.-.w.•.=-•.-.w.-.~•·••>• •,"•W~1,,,,, .. ,,,,,,,,.,WN.•;.,.,,,,.•NN,•NNN.•.-.w. .... -.w<-.. ·• .. ·N.w...,..,_.llN', ..... ,...,,. •• 'llll"_,_,, ... -...,.... II I•.., ·~ ... ~,......_...,..._.........__,._.._ _____ ....,,...,, ................. M_,,._.,,,,._-.,_.M, ..... .. 

• ' , . I 

i 

' AfJllENDU1v11'(0 COU_RT _ORDER - COMPLI.i:1-\NCE. C:ase #: PB2016-003462 I 

l 

To rnaintain public trust' and confidence, the c.aurt· has a duty to ensure that court-appointed Guardians, (:onservators nnd f 

Personaf Representatives co1nply \\1 ith an Court Orders., Cout1· Rules and Arizona Probate La,vs, Therefore, I 

IT IS OR~ERED tht!t the foHo\ving__!as~~ COf!!I?~eted in t~~~ case: ~~---- ·--~~---~--~-- GUARDIANS; CONSElt.\1 A TORS: • "·:;,: ➔ ➔ - _._,,,,,_...., 

1Q~ 1:.suc .. Lct_ters of AJ>poinune_nt \VTthi.n :o, days D Is.sue.~Let,ters of Appointmc.nt \.Vi~hin !~ days 0 l·ile Certificate ot Completion of 1 ram mg O ftle Ceruficate ofCornp[ct1on ot Tram mg 

·within i O days within l O doys 

D Post a Bond within l O davs ., 

PERSONAL REPH.ESENTA1~1\1ES / SPECIAL 

A D!\llNJS'l'RATORS: 

D File Proof of Restrkted /\ccoun1 within 30 days of 

appoint1nent 

0 Issue Lc!tcrs of Appointment within 10 days 

D File Ccrtrficatc of Con1pletion of Traiu ing 

D Fi le Proof of Recnrded Restriction on Re.al 

Property \.Vith in 30 days of appointn1ent 

within l O days t D Fik- ~roof of Annuity Contract. within 60 days of 

0 Post a Bond within 10 days 1 appo1ntn1ent 

0 File or provide proof of maHing of Inventory & 

Appraisen1ent. vvithin 90 days of appoint!ncnt 

D FHe Inventory & Apprajsement within 90 days of 

appohnment 

D File Consumer Credit Report (dated \Vithin 90 days of 

1 the 1nventory & Apprahrerncnt) within 90 days of 

1 _~ppointrn_ent ----------v-·--·-· -··•-N•--··-··--~~~......1 

IT .,!-~-~!!.1!!~1I~_!!~Q!.ID~~E.~ t~at the follo~~Jl.[!Cl'S91~i~).~E.~~!~~£Qn~l!?le f or,·~on1plcting thes.~_!ask~.:.~.~.,a~--------

RESPONSIBLE FIDUCIA.RY: r RESPONSIBLE ATTORNEY: 

Guardian O Attorney for the Fiduciary 

Conservator/Special Conservator D Attorney for the Iristtrance Cornpany 

0 Personal Representative/ Special Administrator D Attorney for the \Vard or Protected Person 

L ..... ~ .......... .............--------- --=--......, s;n.,...._,....._......,....._ ,r JairPl"Lrr• r ,- 1 -~ =•"' ..,"',.,. • ...,,...,._, ... ,.,.....,...........,., 

£4. RE\1IE\V HEARING IS SET TO DE-TERI'vlINE COt\1PLIANCE 

fiJ Review H.caring Date: _ ll/~te: · Time: 8:30 n.m,. 

Hearing Lo,~ntion: 125 W. \Vashington St, Courtroon1 104, llon~ Edward Bassett 

Compliance \\'i1h Bond, ~rraining, and _!:.cttcr~ 9f ~Qfl9_\lltlruatt1⁄4 

D Rt~\1 iew Hearing Date: __________ Time: 8:30 a.m~ 

Hearing Location: 125 \V. Washington St,. Courtroo1n 104, Hon. E<h-,1 ard Bassett 

Compliance with l~estricted Account and R.e.stricted Real Propertyt 

~ U Revie,,., Hearing Date: __________ Time: 8:30 a,n1. 

llearing Location: 125 W, Washington St, Courtroom 104, I-Ion. Ed¥r'ard Bassett 

Co111pliancc with Annuity Contract. 

D Rcvie,v llcaring Datt\: __________ Tin,e: 8:30 a,m. 

llearing Location: 125 ,v. Washington St., Courtroom 104, I-Ion. Ed\\1

ard Bassett 

Compliance with Inventory and Appraisement and Consumer (:redit l<eport.. 

IF YOU lfAYlt COI\1PLff:D ,v1T11 THE ORDEn.s OF THIS COURT, THE REVIE\V HE-AR.INC \VtLL BE 

\lACATEOw YOU \\'ILL NOT BE NfJTJFIED IF A REVIE\V HEARING JS VACATEL>. 

IF YOU BELlEVE YOU liAVE C'OMPLIED \\lJ"fH 1'HE ORDERS OF THIS COUR~r, C0Nl~AC"f PROBATE 

ADMfNISTRAl'ION AT (602) 506--5510., REVIEW FOR COMPLIANCE OCCURS UP TO TflE DATE OF' THE 

HEAUING; THERF~FORE, YOU SHOIJLD CALL TflE DAY BEFORE THE }-{EARING TO SEE IF YOUR 

HEARl~G HAS BEEN VACATED~ 

ALL OTHER QUESTION ABOUT YOUR CASE SifOULD BE DIRECTF.~D TO TIIE C()URT \\.IHERE YOUR CASE 

IS ASSIGNED. 

'. 

DA TEI): October 251 29.16 JUDICIAL OJi~FICER:.....__~~-~l-----.•t~·"'"'""._:::::,-~ ... -- 3 1 c ... 1.,,nBianca -- ---- ~"~~- .. T>T><,.-,- ........ "ff""",T",........,.. ......... T.-r,-,-,"-,-,.-"'"""T>-Y •----. •-,---.-.--..--~-••••-••,••' ,•-"--'•"-·•~-v,.·•.__._.._...,.•..,_....._........._. .. ~ ........ , ............. ,,,.L -..----•-•••4---• 

~ Revised fviarch 13, 2014 

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Name: Muhaymin) Muhammad DOB: Date: 10/25/2016 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 87 of 179
COP 015307

Psych 

Client:: Muhammad Muhaymin 

Client ID: 099 

Date of Log: 12/12/2016 

Current Provider: 

Terros 

Medication Log 

Date of Birth: 

Active Meds 

Inactive Meds 

Allergies 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 88 of 179
COP 015308

lnspbung Change 

fo'lUfe 

Contact Note 

Encounter Date: 01/09/2017 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

11 :20 AM to 11 :24 i\M Duration: 4 min 

Service code: T1016HN53 Units: 1 

Provider n1ade call to client Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F12.10 Cannabis use disorder, Mild Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

Cm called Nluhamn1ad temp guardian to follow up on his passing. ivlussallina informed cm that he did pass but 

she does not know hovv they vvill not release his body or any paper work until after the investigation vvas 

complete. Cm infb1111cd :t\r1ussallina if she needed anything to contact this cm and Nlussallina asked if we had 

any resources that can help pay for his Funeral cost. Ctn informed lviussallina she would put out an en1ail 

ask.ing for resources and get back to her if she hears of any. 

Staff case. 

Indicators 

Electronicallv signed by: Kimberly Bryant Bll'f Isl 

Provider Signature 

01/09/2017 03:04 PM 

Date 

l.Jser Signature (person completing form): Electronically Signed By: Kimberly Bryant 

CIS ID: 099 

AHCCCS ID: ~335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 89 of 179
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Contact Note 

Encounter Date: 01/06/2017 3:32 l'l\1 to 3:33 PlVI No billing tor service 

Patient Name: Muhammad Muhaymin 

Provider Name: 1\my Beard BH1' 

Provider received e-mail from case ,nanager. Contacted for coordination of care. 

D 1annos1s Add resse d T d o av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

From: Rasheedah Sl1al1eed 

Sent: Thursday, January 05, 2017 3:32 PM 

·ro: 1'homas Bohanske <'fho1nas.Bohanske(q)terros.org> 

Cc: ,A.my Beard <:;\Jny.Beard(glten,os.org> 

Subject: Muhann11ad I\1. [secure] 

New OR Continuing 

Continuing 

IIello 'fom ... Jiere is the way I found out l\1uhall1Inad lvL had passed away: On 1ny ,vay home from ,vork 

yesterday (1/4/2017) I observed Phoenix P.D at Maryvale library ,vith yello,v tape out and nun1erous police 

cars and mobile units, I k.new l'v!uham.mad was homeless in the park. behind the library so this Cl\1 ,vent to check 

on him. I looked around for l\1uhall1J11ad as I located his belongings, however, he was not arou11d. CM asked 

individuals in the park who he hung ,vith if they had seen him. This is when I was informed that he was killed 

earlier that mo1ning and that's why the police were still in the area. Ci\1 saw one ofMuhann11ad's sister's in the 

park as she spoke ,vith this CM and clarified that it was Muhan1n1ad that had been killed by the police. I hung 

around for a while providing support to the sister and then spoke wit . I hung around for a while providing 

support to the sister and then spoke with a female detective who also clarified that Muhanunad was dead. 

Today, 1/5/17, I tried to contact Muhammad's guardian ,vhich is one of his sister's, ho,vever, there was no 

answer. Caine in to work. today and notified CC, AI11y of the incident 

Rasheedah Shaheed 

Case Manager 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 90 of 179
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5030 W NlcDowell Rd, Ste 16 o Phoenix, AZ 85035 

P: 602-278-1414 

Indicators 

Electronicallv sigt1ed by: .A.mv Beard BHT Isl 

Provider Signature 

lTser Signature (person completing form): Electronically Signed By: Amy Beard 

CIS ID: 099 

J'.\HCCCS ID: ...-J335 

01/06/2017 03: 5 2 P:tvl 

Date 

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Contact Note 

Encounter Date: 12/12/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

9:22 AM to 9:30 i\M Duration: 8 min 

Service code: 0001A Units: 1 

Provider drive titne self at l\1aryvale Park. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F12.10 Cannabis use disorder, Mild Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

Cm drove back to Mm.y-vale Park .. 

Cm meet to update assessn1ent 

Indicators 

Electronicallv signed by: Ki1nberly Bryant BI-fr Isl 

Provider Signature 

12/12/2016 04:03 PM 

Date 

User Signature (person con1pleting fom1): Electronically Signed By: Kimberly Bryant 

CIS ID: -,099 

AHCCCS ID: ~335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 92 of 179
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Contact Note 

Encounter Date: 12/12/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

9:05 AM to 9:20 i\M Duration: 15 min 

Service code: 0001A Units: 1 

Provider drive titne self at Office. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F12.10 Cannabis use disorder, Mild Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

Cm drove back to the clinic to get a ne,v computer to co1nplete Muhammad assessment. 

Client scheduled. 

Indicators 

Electronicallv signed by: Ki1nberly Bryant BI-fr Isl 

Provider Signature 

12/12/2016 04:00 PM 

Date 

User Signature (person con1pleting fom1): Electronically Signed By: Kimberly Bryant 

CIS ID: -,099 

AHCCCS ID: ~335 

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Contact Note 

Encounter Date: 12/12/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

9:00 AM to 9:14 i\M Duration: 14 min 

Service code: 0001A Units: 1 

Provider drive titne self at Hon1e. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F12.10 Cannabis use disorder, Mild Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

Cm drove to I\1aryvale Park to finish updating Muhmrunad assessn1ent and ISP. 

Cm \Vill con1plete ISP 

Indicators 

Electronicallv signed by: Ki1nberly Bryant BI-fr Isl 

Provider Signature 

12/12/2016 02:11 PM 

Date 

User Signature (person con1pleting fom1): Electronically Signed By: Kimberly Bryant 

CIS ID: -,099 

AHCCCS ID: ~335 

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Progress Note 

f:ncounter Date: 12/ I. 2/20 16 09:30 AM to 11 :00 AM Duration: 90 mi.n 

Patient Nan1e: 

Service Code: T1016HN99 U11its: 6 

Muhammad Muhaymin 

Patient 11): 3099 

Provider Name:Ki1nberly Bryant BHT 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description New OR Continuing 

Fl2.10 Cannabis use disorder, Mild Continuing 

F20.9 Schizophrenia Continuing 

Data 

1'his session was held at !vlaryvale I>ark. with the following person( s) in attendance: 

l)iscussion and I11terventions: 

Case wianagement: activities may include assisting, 1naintaining, and monitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach and 

follow up, and other activities as needed. 

Cm meet \Vith wiuhaffilnad and his guardian/sister I\1ussallina at :t\1aryvale Park to con1plete his assess1nent and 

ISP. Ctn ask.ed ~luhanunad all the questions on the assesstnent and what Muhan1111ad could not answer ~lussallina 

answered for Muhammad. Cm informed !vf uhann11ad and !vlussallina that she ,:vould finish up 1\1uha1m11ad ISP and 

go over it with both oftl1en1 and have then1 sign it. Ctn got l\.,fuhan1111ad goals and strength's 

Living Goal: I ,vant own apartment/ l\.,f uhammad needs to keep in touch with cm ru1d guardian for updates on his 

housing. 

Lean1ing/Working Goal: I want to work pat1-time to earn money/ l\1uhannnad will n1eet with RS for supportive 

employment 

Social Goal: I want attend community groups/ wluhammad will meet with RS to coffi111unity support se Living 

Goal: I want own apartment/ l\1uha1111nad needs to keep in touch with cm and guardian for updates on his housing. 

Lean1ing/Working Goal: I want to ,vork part-time to earn money/ Muhammad will 1neet with RS for suppottive 

employment 

Social Goal: I want attend community groups/ wiuhammad will meet with RS to comn1unity support services. 

Health Goal: I want to visit \Vith PCP yearly for routine check-up/ Muhammad 111eet with the PCP for intake. 

Strength's 

:tvfuhrunmad has ,vork history 

Muhannnad has the support of his family 

:tvfuhrunmad has the support of the clinical tea1n 

Muhan1111ad \Vill attend his appointments 

J\.1uhrumnad cru1 cook and clean 

Muhan1111ad utilize tl1e transit system 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 

Revision Date: 6/li00 

1\1.R. #: Prog. Note 12/12/2016 2:08 Pl\1 IZin1berly B:ryant 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 95 of 179
COP 015315

Muhann11ad has support from his dog 

J\1uhannnad does get food sta,nps 

Muha1nn1ad car drive 

J\1uhannnad has Associate's Degree 

Cm informed Muhammad of getting a letter fron1 a doctor for his services dog and he ,vould be able to bring his dog 

to the clinic. cm info1n1cd J\1uha1nn1ad about the Christmas party and Muhammad said he would like to come ifhc 

could find a babysitter for his dog. Cm infon11ed Muhanm1ad she ,vould schedule a cab for the 14th at 10:30am. 

Assessment 

Cit presented with sx oflTse of Drugs and Alcohol. Barriers to progress are Housing, incon1e. Clt's affect is good 

eye contact, walked around and was cleaning. l'v!ood appears to be elevated, friendly. 

Client has no SI/HI Ideation. 

Progress 

Steady progress. 

Plan 

Continue services. 

Electronicallv Signed By: Kimberly Bryant B}IT 

Provider Signature 

Page 2/2 Pt. Name: MuhaYJnin, Jvluhan1n1ad 

Revision Date: 6/liOO 

12/1212016 03:48 Pl\1 

Date 

l\1.R. #: Prog. Note 12/12/2016 2:08 Pl\-1 Kiniberly Bryant 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 96 of 179
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Contact Note 

Encounter Date: 12/05/2016 12:11 I>l\1 to 12:12 Pl\tl Dura.tion: 1 min 

Service code: A01104 U1lits: 1 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Amy Beard BHT 

Provider provided bus pass to client. Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Provided monthly, regular tare bus pass, #L31-729523 

Indicators 

Electronically signed by: A111y Beard BHT Isl 

Provider Signature 

·user Signature (person completing form): Electronically Signed By: Amy Beard 

CIS ID: 099 

AHCCCS ID: ~335 

New OR Continuing 

Continuing 

12/29/2016 01:45 PM 

Date 

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Progress Note 

f:ncounter Date: 12/05/2016 10:00 AM to 12:10 PM Duration: 130 min 

Service Code: T1016HN53 U11its: 9 

Patient Nan1e: Muhammad 

3099 

Muhaymin 

Patient IJ 

Provider Name:Ki1nberly Bryant BHT 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description New OR Continuing 

Fl2.10 Cannabis use disorder, Mild Continuing 

F20.9 Schizophrenia Continuing 

Data 

1'his session was held at ()ftice \vith the following person( s) in attet1dance: 

l)iscussion and I11terventions: 

Case wianagement: activities may include assisting, 1naintaining, and monitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach and 

follow up, and other activities as needed. 

Cm sat in ivith Muha1ru11ad, guardian Mussallina, step n1other, and Dr. Villalobos at his appoit1ttnent evaluation. 

Dr. Villalobos a5ked Muhamn1ad the questions and the ones he could not answer his guardian did tl1e best they 

could. Cm sat and asked !vf uhann11ad a few questions to help Dr. Villalobos get the n1ost con·ect ans\ver, after his 

appointment cm took Muhan1n1ad and his guardian back. with his ctn to fill out a housing application and 

VI-SPDAT. Cm asked the questions on tl1e VI-SPDAT and housing application and Muhammad answered the best 

he could, cm informed Muhan1111ad that the clinic will be moving and on the 9th of January \Ve will be located by 

the park :tvluhammad in currently staying at. Cm asked Muha1111nad if he would like to finished his assessment and 

ISP due to Jv1uhanunad fallen asleep. Muhammad said he would lik.e to continue late, cm said she would go by the 

park later this week to finish his assessment. Cm said she would go by on Wednesday or Friday. Cn1 walked 

Muhan1111ad and his guardian out and ret11inded Mussallina this ct11 would call when the doctor was finished with 

her court documents she needed filled out. lvfuha111111ad asked cm ifhe could get a 111onthly bus pass, cm ,valked 

lvluhan1111ad and his guardian up to the fi·ont lobby and filled out the monthly bus pass f on11 for Muha1mnad to sign, 

bus form number 1,31-729523. 

Assessment 

Clt presented with sx of presented, lJse of Dn1gs and Alcohol, Confusion. Barriers to progress are Stability. Clt's 

affect is constricted. Mood appears to be euphoric. 

Client has no SI/HI Ideation. 

Progress 

Slow progress. 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 

Revision Date: 6/li00 

1\1 . R. #: Prog. Note 12/05/2016 1 : 17 P l\1 IZin1 berly B:ryant 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 98 of 179
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Plan 

Electronicallv Signed By~Ki1nberlv Bryant BH'I' 

Provider Signature 

Page 2/2 Pt. Name: MuhaYJnin, Jvluhan1n1ad 

Revision Date: 6/liOO 

12/05/2016 01:36 PM 

Date 

l\1.R. #: Prog. Note 12105/2016 l:17 Pl\1 Kiniberly Bryant 

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Psychiatric Progress Note 

Encounter Date: 12/05/2016 

Provider: 

Patient Name: 

Submitted Code(s): 

Lilliam Villalobos MD 

Muhammad Muhaymin 

Start Time: 10:24 A~A End Time: 11 :00 AM 

Non EM Code: 90792 Unit: 1 

Open in errorr 

Pagel of 1 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

No billing for service 

Age: 43 Years 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 100 of 179
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Contact Note 

Encounter Date: I 1/18/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

2:20 l'l\1 to 2:30 PlVI Duration: 10 min 

Service code: T1016HN53 Units: 1 

Provider n1et ,vitb guardian at Office. Contacted for coordination of care. 

Diannosis Addressed Todav 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

('ase Managen1ent: activities ,nay include assisting, maintaining, and ,nonitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and follovv up, and other activities as needed. 

l\1uhanunad guardian can1e into the clinic to inforn1ed cin that she needed ,nore information of tl1e guardianship 

pape1work, Mussallina inforn1ed cn1 when she went to the judge they gave her more tin1e because the 

pape1work was not filled out vvith enough information. Mussallina informed cm she needed the to have it done 

by the I st of December. Cm infon11ed Mussallina that she ,vould email the doctor due to her being off and cn1 

will contact her on l\1onday to see if the doctor ,vants hi111 to come back in or if she would fill it out Cm 

emailed tl1e doctor and vvill follow up on l\1onday. Mussallina said she would contact cm on Monday. 

From: Kimberly Bryant 

Sent: Friday, November 18, 2016 3:24 PM 

To: Lilliam Villalobos <Lilliam. Villalobos@terros.org> 

Cc: Amy Beard <Amy.Beard@terros.org> 

Subject: Muhammad M 

Hello 

Mussallina came in for Muhammad and asked if you could put more information with the report, Mussallina 

informed me the judge gave her more time because she said the guardianship paperwork needed to be filled 

out with more accurate information on Muhammad. Mussallina said she needed it by the 1st of December 

and his next appointment is on 12/5/16. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 101 of 179
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Thanks 

Staff case. 

Indicators 

. 

. Kimberly Bryant 

Case Manager 

Electronicallv signed by: Ki1nberly Bryant BI-fr Isl 

Provider Signature 

11/18/2016 03:14 PM 

Date 

User Signature (person con1pleting fom1): Electronically Signed By: Kimberly Bryant 

CIS ID: :,099 

AHCCCS ID: ~335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 102 of 179
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Progress Note 

f:ncounter Date: 11/1.4/2016 02:31 P~I to 03:25 PM Duration: 54 mi.11 

Service Code: T1016HN53 U11its: 4 

Patient Nan1e: Muhammad 

3099 

Muhaymin 

Patient 11): 

Provider Name:Ki1nberly Bryant BHT 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Data 

'fhis session was held at ()ffice with the following person(s) in attendance: 

Discussion and Interventions: 

Case Management: activities n1ay include assisting, n1aintaining, and n1onitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach and 

follow up, and other activities as needed. 

Cm meet \Vith lviuhannnad and his step mother Annie who can be reach at 2685. Ctn 111eet with 

Muha1n1nad and his step n1other to con1plete his assesstnent and ISP. Muhan1n1ad infonned ctn he was tried and 

asked ifhe could do half today and half when he come back in for his appointment. Cm informed Muha1runad and 

his step n1other this ctn could break it into t,vo parts. Ctn asked lvluhann11ad the questions on the his assessment, 

lviuhru1m1ad and his step 1nother Annie answered the questions this cm asked. lviuhammad asked ifhe could get a 

bus pass and ctn filled out the fon11 and gave Iv1uha1nn1ad his monthly bus pass. Cn1 informed I\i1uhannnad this 

clinic had a PCP since 11uhamn1ad did not have one ru1d gave him the name, address, and number phone to the PCP 

cm asked Muhamt11ad what he was wanting for the clinic and Muhan1111ad said ~rhat ever the clinic cam e do for 

hitn. Muhanm1ad did ask for counseling and cm infon11ed Muhammad this cn1 will set him up for counseling. Cm 

walked Muhan1111ad to the fi·ont and made hin1 an appointment for 12/5/16. Muhammad did talk at times but 

would also use hand gestures ru1d his step 1nother would answer the questions for Muhamn1ad when Muhammad 

could not ren1en1ber. 

Assessment 

Clt presented with sx of presented okay used hand gesture at tin1es,, Fatigue. I3arriers to progress are Stability, 

substance use. Mood appears to be euphoric. 

Progress 

Slo,v progress. 

Plan 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 

Revision Date: 6/li00 

1\1.R. #: Prog. Note 11/14/2016 3:18 Pl\1 IZin1berly B:ryant 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 103 of 179
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Electronicallv Signed Bv: Kimberly Bryant BHT 

Provider Signature 

Page 2/2 Pt. Name: MuhaYJnin, Jvluhan1n1ad 

Revision Date: 6/liOO 

11/14/2016 04:31 PM 

Date 

l\1.R. #: Prog. Note 11/14/2016 3:18 Pl\-1 Kiniberly Bryant 

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Psychiatric Progress Note 

Encounter Date: 11/14/2016 

Provider: 

Patient Name: 

Submitted Code(s): 

Lilliam Villalobos MD 

Muhammad Muhaymin 

Start Time: 02:00 PM End Time: 02:30 PM 

EM Code: 99214 Unit 1 

Reason for Treatment: 

Presenting issues/Chief Complaint: I am as ok as I can be. 

Age: 43 Years 

Patient came accompanied by Stepmother, she brought some paperwork for the Guardianship, we 

discussed that her daughter was given the same paperwork filled out last appt, patient remains homeless, 

presented casually dressed, clean, had his dog with him, responded questions when asked, disorganized, 

moderate FOi, LOA, when asked if he was sleeping he said 'earth'\ appetite ok, denied any S/H ideations, 

questionable hall, did not answer accordingly. Drug use hx, drug of choice cannabis. 

Recommendations: 

Plan reviewed: 11/14/2016 

Schedule appt for a Psych Eval. 

CSPMP reviewed. No opiates rx'ed. 

Once Psych Eval completed I will consider rx meds. 

Continue to provide Supportive Therapy. 

Contact Case Manager with any concerns. 

Practice Sleep Hygiene. 

Continue compliance with Clinical Team recommendations. 

Encourage proper hydration, nutrition and exercise. Regular Diet. 

Risk factor reduction: Avoid stressful situations; contact Clinical Team with any concerns. 

Contact the Crisis Line if he becomes DTO/DTS. 

Follow up with PCP for Medical Concerns. Denied any now. 

RTC with Psychiatrist in 4 wks or as needed. 

RTC with RN for labs or as needed for triage. 

Psychosocial stressors: Housing stressors are severe. 

Review of Systems: 

Reviewed, NO changes 

Ears, Nose, Throat: Negative 

Pagel of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 105 of 179
COP 015325

Constitutional: 

Cardiovascular: 

Endocrine: 

Gastrointestinal: 

Genitourinary: 

Hematological: 

Immunologic: 

Musculoskeletal: 

Respiratory: 

Skin/Breast: 

Eyes: 

Neurological: 

Psychiatric: 

Histories: 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Positive Additional Detail: psychotic 

Reviewed with NO Changes 

Past Medical History 

Past Medication: Has not taken meds in a long time. Treated while in jail but does not remember name. 

Developmental History: Normal 

History of injury, illness, and seizures: Denied. 

Meds Reported at Intake: 

Family History 

Mental illness in family: Cousin : Schizophrenia 

Substance abuse in family: Unknown 

Suicide attempts in family : Unknown 

Violence in family : Denied 

Medical problems in family: Mother died 

Father died 

other comments: 

Social History 

Client is homeless. Living situation is stressful. 

Mental Status: 

Client is a 43 year old, male. Dressed appropriately. Appears age and normal weight. Client is 

well-groomed. Oriented to situation, place, person. Level of alertness is normal. Eye contact is good. 

Speech quantity is diminished with slow rate and diminished amplitude. Client has no mannerisms of 

note .. Thought processes: tangential. Associations: very loose. Stream of thought is tangential. Reports 

no delusions.. No hallucinations reported. 

Client is not DTS. Client is not OTO. Sleep: fair. Appetite: good. Mood: congruent. Affect: flat. Fund of 

knowledge: fair. Memory: fair. Insight: poor. Judgement: poor. Concentration: poor. 

Observed Gait : Steady. Muscle Strength and Tone appears: Normal. 

Client did not report danger to otl1ers (DTO). 

Client did not report danger to self (D'fS). 

Page 2 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 106 of 179
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Medication Effectiveness and Side Effects: Client or Guardian reports experiencing no side effects to 

meds. 

Medical Data: 

No accidents, injuries or serious illnesses reported. 

Substance Use: 

Admitted to smoking cannabis 

Current Meds: 

Axis I - DSl\11 -IV 

295. 90 Schizophrenia UnditTerentiated Type 

Axis II: 

V71.09 

Axis III: 

Axis Ill: 

Axis IV: 

Axis V: 

NONE 

NONE 

No diagnosis on Axis II 

Problems with/related to housing, 

NONE 

DSM-V 

F20.9 Schizophrenia 

Treatment Plan: No progress with Tx plan. Medications were not changed. 

The following were discussed with the client: Client or guardian understood and made an informed 

decision. 

Cit to be seen in 4 weeks. 

MOM - Problem Points 

Problem 

Disorganized 

Problem 

Disorganized 

Plan Desc 

No Plan 

Problem Detail 

New to Examiner 

Chonic Acute Workup 

Chronic No Additional Workup 

Medical Decision Making (data points): 

NatureDesc 

Worsened 

Notes 

Needs psych eval 

1 Obtained history from someone other than the patient OR made decision to obtain records 

~ Revie\Ned and summarized records and obtained records and or had a discussion with another health care provider 

Risk: Moderate Risk 

Electronically Signed By: Lilliam Villalobos MD 

Document generated and completed 11/14/2016 02:36 PM 

Page 3 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

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Page 4 of4 

Name: Muhanunad i\-1uhayinin ClS ID: ....,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 108 of 179
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Contact Note 

Encounter Date: 11/14/2016 3:26 I>l\1 to 3:27 Pl\tl Dura.tion: 1 min 

Service code: A01104 U1lits: 1 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Amy Beard BHT 

Provider provided bus pass to client. Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Provided monthly, regular tare bus pass, #L31-721696 

Indicators 

Electronically signed by: A111y Beard BHT Isl 

Provider Signature 

·user Signature (person completing form): Electronically Signed By: Amy Beard 

CIS ID: 099 

AHCCCS ID: ~335 

New OR Continuing 

Continuing 

11/30/2016 11:28 M1 

Date 

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Contact Note 

Encounter Date: I 1/04/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

8:31 AM to 8:45 .4M Duration: 14 min 

Service code: T1016HN53 Units: 1 

Provider attended staffing with guardian. Contacted for coordination of care. 

Diannosis Addressed Todav 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

('ase Managen1ent: activities ,nay include assisting, maintaining, and ,nonitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and follo,v up, and other activities as needed. 

('m ,neet ,vith Mussallina to go over Mul1m11111ad intake packet m1d have the guardim1, sign the necessary paper 

fi·on1 Muhan1111ad intake packet. Cm informed Mussallina when she n1eet Muhammad he ,vas talking but the 

second tin1e he was doing the hand gestures. Cn1 informed l\1ussallina !1,1uhan1mad had appointment on the 14th 

and this cm was goi11g to sit down with hi1n and his step mother to complete his assessment and ISP ,vhich are 

his goals. Cm explained she talked ,vith l\1uhmnmad about this m1d he did say he ,vanted help getting hin1 

apartn1ent, Mussalli11a said that ,vould be fine with her for cm to complete the assessn1ent with Jvluhm11111ad and 

his step mother beeat1se she knows lvluhammad better. Cm ask.ed 11,!ussallina about cou1iug to l\1uhammad 

appointments a and she informed cm she could not con1e to everyone but if this c1n could informed her about 

the appoinl!nents and give her an update on the ones she could not n1ake it to. lvlussallina asked if this c1n was 

able to get the papervvork from CPR/ or the prison cm informed lvlussallina they did get the papervvork fron1 

CPR so at his nel\i appointn1ent the doctor should he able to fill out the court paper she needed for guardianship. 

Cm ,vent over the intake packet and had l\1ussallina sign it cn1 gave copy of the intake packet to l\1ussallina and 

walked her out to the lobby. 

Staff case. Cn1 staffed witl1 guardian l\1ussallina 

Indicators 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 110 of 179
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Electronicallv sigt1ed by: Ki1nberly Bryant BHT /s/ 

Provider Signature 

11/04/2016 10 :07 AM 

Date 

1.Jser Signature (person co1npleting fonn): Electronically Signed By: Ki1nberly Bryant 

CIS ID: 099 

AHCCCS ID: ~335 

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Contact Note 

Encounter Date: 11/02/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

11 :26 AM to 11 :35 i\M Duration: 9 min 

Service code: 0001A Units: 1 

Provider drive titne self at Office. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

cn1 drove back to the office 

Indicators 

Electronically signed by: Kin1berly Bryant BH'f Isl 

Provider Signature 

New OR Continuing 

Continuing 

11/02/2016 02:06 PM 

Date 

·user Signature (person completing form) : Electronically Signed By: Kin1berly Bryant 

CIS ID: 099 

AHCCCS ID: ~335 

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Contact Note 

Encounter Date: 11/02/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

11:11 AM to 11 :25 i\M Duration: 14 mbt 

Service code: 0001A Units: 1 

Provider drive titne self: client J\,1uha1runad at 99 Cent Store. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Cm drove I\1uhrurunad to the 99 C~ent Store per clietn request 

Drove client to 99 Cent Store 

Indicators 

Electronicallv signed by: Ki1nberly B1yru1t BI-IT /s/ 

Provider Signature 

New OR Continuing 

Continuing 

11/02/2016 02 :03 Pivl 

J)ate 

1.Jser Signature (person co1npleting fonn): Electronically Signed By: Ki1nberly Bryant 

CIS ID: 099 

AHCCCS ID: ~335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 113 of 179
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Contact Note 

Encounter Date: 11/02/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

10:21 AM to 10:34 i\M Duration: 13 mbt 

Service code: 0001A Units: 1 

Provider drive titne self: client J\,1uha1runad at park behind Maryvale Hospital. Contacted for coordination of 

care. 

. Add Iaanos1s resse ct T o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Cm drove Muhan1111ad back to the park behind Maryvale hospital. 

I\1eeting at the park to co1nplete intake packet 

Indicators 

Electronically signed by: Kin1berly Bryant BH'f Isl 

Provider Signature 

New OR Continuing 

Continuing 

11/02/2016 01:59 PM 

Date 

User Signature (person completing form): Electronically Signed By: Ki1nberly Bryant 

CIS ID: 099 

AH(:c:cs IL): ~335 

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Contact Note 

Encounter Date: 11/02/2016 10:05 AM to 10:20 i\M 

Patient Name: Muhammad Muhaymin 

Provider Name: Kimberlv Bryant Bll1' v • 

Provider drive ti1ne client, self at Office. Contacted for coordination of care . 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Cm drove Muhan1111ad to the clinic to complete his intake packet 

Co1nplete intake packet 

Indicators 

Electronically signed by: Kin1berly Bryant BH'f Isl 

Provider Signature 

New OR Continuing 

Continuing 

11/02/2016 01:50 PM 

Date 

·user Signature (person completing form) : Electronically Signed By: Kin1berly Bryant 

CIS ID: 099 

AHCCCS ID: ~335 

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Contact Note 

Encounter Date: 11/02/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

9:45 AM to 10:00 i\M Duration: 15 min 

Service code: 0001A Units: 1 

Provider drive titne self at park beind hospital. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Cm drove to the park behind rvtaryvale Ilospita1 to 1neet with Muha1namd ru1d bring hin1 to the clinic to 

complete his intake packet. 

I\1eet ,vith Mul1ai1m1ad 

Indicators 

Electronically signed by: Kin1berly Bryant BH'f Isl 

Provider Signature 

11/02/2016 01:46 PM 

Date 

User Signature (person completing form): Electronically Signed By: Ki1nberly Bryant 

CIS ID: 099 

AH(:c:cs IL): 11111)335 

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Contact Note 

Encounter Date: I 1/02/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

12:15 l'l\1 to 12:25 PlVI Duration: 10 min 

Service code: T1016HN53 Units: 1 

Provider left 1nessage for client. Contacted for coordination of care. 

Diannosis Addressed Todav 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

('ase Managen1ent: activities ,nay include assisting, maintaining, and ,nonitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach 

and follo,v up, and other activities as needed. 

('tvl called I\1uhanunad guardiru1 and let her know c1n ,neet with Muhan1111ad today to go over the intake 

prescreen packet. Ctvl explained what ,vas in the packet adv/Directive, consent BI, Copay, Email/Vn1 Consent, 

Handbook, Notice of legal rights, and rec oftice Information. C111 e,q,lained she gave tvluhan1111ad a copy of the 

handbook and asked if this c111 could come by to have her sign as well since she was the guardian for 

l\4uha1111nad. tvlussallina informed cm that her work schedule was crazy since she will be taking out work for a 

fe,v weeks and it would be easier for her to come to tl1e clinic to sign ilie papenvork. l\4ussallina did not give 

this CJn a day when she would be con1ing in, cm informed Mussallina she would be in the office all day on 

Thursday and Friday would be in and out all mon1ing but in most of the aften1oon on Friday. Mussallina asked 

if she came by and tl1is c111 was not there could so1neone else help her on the tean1. Ctn explained yes and that 

she would staff with the team so the team ,vould ki10,v she would be con1ing in. Cm infon11ed Mussallina that 

Muha1n1nad ,vas usi11g ilie hand gestures today and not talking, cn1 infonned Mussallina that this cn1 intonned 

tv!uhru1m1ad of his appoint1nent on 11/14 and let him kilow tl1ere step-mother would be bring hi1n in. Ctn said 

she ,vould call to re111inded hi1n the day before. Cn1 asked Mussallina since the step-n1otl1er ki1ew Muhru111nad 

best if it would be alrigl1t to complete his assessn1ent and get his ISP goal so cm could start helping him in the 

areas tv1uhanunad wanted help in. tvlussallina said yes that ,vould be better because the step n1other raised 

tv!uhru1m1ad and she could ru1s,ver tl1e questions iflv1uhamn1ad was playing mute again. Cm tl1anked 

Mussallina and hung up the phone. 

Client scheduled. l\4ussallina ,vill come in to sign the intake prescreen packet 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 117 of 179
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Indicators 

Electronically signed bv: Ki111berly Bryant BH1' /s/ 

Provider Signature 

11/02/2016 01 :09 PM 

Date 

·user Signature (person completing fonn): Electronically Signed By: Kimberly Bryant 

CIS ID: _,099 

AIICCCS ID: ~335 

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Progress Note 

f:ncounter Date: 11/02/2016 10:35 AM to 11:10 AM Duration: 35 mi.n 

Service Code: T1016HN99 U11its: 2 

Patient Nan1e: Muhammad 

3099 

Muhaymin 

Patient 11): 

Provider Name:Ki1nberly Bryant BHT 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Data 

'fhis session was held at Park behind tv1aryvale 1-Iospital with the following person(s) in attendance: 

Discussion and Interventions: 

Case Management: activities n1ay include assisting, n1aintaining, and n1onitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach and 

follow up, and other activities as needed. 

Cm meet \Vith lviuhannnad at the park behind Maryvale Hospital, c1n asked Iv1uhru1nnad ifhe would con1e to the 

clinic with this ctn. to fill out his intake packet. lvluhammad gestured yes with a nod of his head. Cm drove 

1v1uhru1nnad to the clinic and once there Muha1ru11ad did not want to get out of this cm car. Cn1 asked Muhammad if 

he was going to con1e into the clinic ru1d Muhatrunad gestured no \vith his head, cm asked Ivfuha1n1nad were he 

wanted to complete his intake packet and lvluhammad gestured by pointing in cm car. Cm asked Muha1nn1ad ifhe 

would be 1nore con1fortable in his O\Vll eletnent ( at the park) and lvluhammad said yes. Cm went and got the laptop 

and drove lviuhru1m1ad back to the park to conducted the question. Ctn explained to Muhammad what they will be 

going over. Cn1 explained the adv/directive, consent BI fon11, email/vn1 consent, handbook( and gave him a 

handbook as well), bnotice of legal rights, rec office infonnation, ct11 e.>i.'Plained and read off each of these forms to 

Muhan1111ad and asked ifhe understood everything cn1 explained to hin1 in his intake packet. Muhammad nodded 

yes and cm asked lvluhammad if he could sign the fo1111s. lvluhammad signed the forms . Cm talked with 

Muhan1111ad of\vhat he is asking the clinic to help hin1 with and ifhe knew ,vhat the clinic/1''erros was about. 

Iviuhrunmad said no, ctn explained the purpose of having a case manager ru1d being involved in the clinic services to 

l\1uhan1111ad, ctn explaiend ,,,hat the ISP was and asked Ml.Jl1ammad about son1e of his goals he 1nigl1t want help 

with. Cn1 explained the purpose of RS and VR and if:tvluhann11ad \Vanted help with finding e1nployment or housing 

the clinic could help him \Vith that. Cn1 asked l\1uhan11nad about his substance use and ifhe would like substance 

abuse counseling or try a treattnent place1nent to help with his substance use. Muhan11nad gest11re with his head but 

cm is unsure to what kind ofhelp he would like. Cm asked lvfuha1n1nad if they could go over it when he co1nes for 

his appointtnent on tl1e 14th ru1d l\1uhrumnad said yes. Cin asked Muha1runad if this cm called ,vould he pick up the 

phone and lvf uhamamd gestured yes. Cm explained to :rv1uha1nmad his step mother ,votlld be coming with hin1 to his 

appointments. !\1uhrurunad gestured to c1n if she could take hi1n to the store to get something to eat. Ctn said she 

would and asked Muhamamd how he came to Ten·os. :rv1uha1nmad tried to gesture ,vhere he ,vas before T erros and 

cn1 gave l\;f uhanm1ad a piece of paper and pen to write it down. I\r1uha1runad wrote out he can1e fi·om Fort Grant 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 1\1 .R. #: Prog. Note 11/02/2016 10:06 .. Al\1 Kiinbcrly Bryant 

Revision Date: 6/li00 

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Prison. Cn1 drove l'vluhammad to the 99 cent store and C111 re1nined Muhann11ad about his appointn1ent and said if 

he needed anything to contact this c1n or the clinical terun. 

Assessment 

Cit presented with sx oflTse ofD1ugs and .,\!coho!, Overactivity, Muha1runad talked with han,l gestures, could not 

keep still while completing the intake. Ba1riers to progress are Ho1nelessness, Substance. Clt's affect is constricted. 

l\1ood appears to be quiet, using gestures to talk. 

Client has no SI/HI Ideation. 

Progress 

No progress. 

Plan 

Electronicallv Signed By Kin1berlv Brvant BIIT 

Provider Signature 

Page 2/2 Pt. Name: MuhaYJnin, Jvluhan1n1ad 

Revision Date: 6/liOO 

11/02/2016 02:00 I'M 

Date 

l\1.R. #: Prog. Note 11/02/2016 10:06 Al\1 Kirnberly Bryant 

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Contact Note 

Encounter Date: I 0/27/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

9:20 AM to 9:40 i\M Duration: 20 min 

Service code: 0001A Units: 1 

Provider drive titne self: ctn Rasheedah at park behind r...1aryvale Hospital. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fa111ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

C:tvl drove to tl1e park behind I\,faryvale llospital to n1eet ,vith Muhammad for the first tin1e. 

Client scheduled. Cm will meet V1rith Niuhan1111ad of Tuesday 

Indicators 

Electronicallv signed by: Ki1nberly B1yru1t BI-IT /s/ 

Provider Signature 

10/2712016 03 :3 8 Pivl 

Date 

User Signature (person con1pleting fom1): Electronically Signed By: Kimberly Bryant 

CIS ID: -,099 

AHCCCS ID: ~335 

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Progress Note 

f:ncounter Date: 10/27/2016 09:40 AM to 10:00 AM Duration: 20 mi.n 

Patient Nan1e: 

Service Code: T1016HN99 U11its: 1 

Muhammad Muhaymin 

Patient 11): 3099 

Provider Name:Ki1nberly Bryant BHT 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Data 

'fhis session was held at Park ,vith the follo,ving person( s) in attendance: 

Discussion and Interventions: 

Case Management: activities n1ay include assisting, n1aintaining, and n1onitoring covered services, finding 

necessary resources to meet basic needs, coordinating care with fan1ily and other agencies involved, outreach and 

follow up, and other activities as needed. 

This cm along \Vith c1n Rasheedah went to the park behind 1v1aryvale Hospital, cn1 Rasheedah introduced this cm to 

Muha1n1nad. Ctn asked ~Iuhann11ad if it was okay for hitn to con1e in next week. and finished up some papenvork. 

1v1uhannnad said he would con1e to the clinic on Tuesday, cm said she would come to the park and pick hin1 up 

around the san1e ti1ne on ·r uesday. Muhan1111ad infonned ctn he was on his way to get his food stan1ps. Muhamn1ad 

asked this cm ifhe could have a ride to 47th Ave Indiru1-School to the DES office. CM said yes and asked 

Muha1n1nad \vhere lie came from, Muhan1111ad said 4th Ave jail. CM drove Muhan1111ad to the DF.:S office and 

reminded hin1 this cn1 will pick hin1 up on Tuesday around 1 0an1. 11uhamn1ad presented \¥ell~ dressed 

appropriately for the weather. 

Assessment 

Clt presented with sx of presented well. Ban·iers to progress are Housing, stability. 

good. Nlood appears to be friendly. 

Clt's affect is eve ., contact was 

Client has no SI/HI Ideation. 

Progress 

Slow progress. 

Plan 

No homework given today. 

Electronicallv Signed Bv: .... Kimberly Bryant BHT 

Provider Signature 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 

Revision Date: 6/li00 

10/27/2016 03 :34 PM 

Date 

1\1.R. #: Prog. Note 10/27/2016 2:42 Pl\1 IZin1berly B:ryant 

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Page 2/2 Pt. Name: MuhnYJnin, Jvluhan1n1ad l\1.R. #: Prog. Note 10127/2016 2:42 Pl\.1 Kiniberly Bryant 

Revision Date: 6/liOO 

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Tcrros 

Case Consultation N'ote 

Client N an1e: l\fuhanunadMu.l1avi1m1 ., l)OB: Date: 10/27/2016 

Client ID: 099 

Reason for Case (:onsultatio11: Coordination of care 

Curre11t Diagnosis: 295.90 Schizophrenia lJndifferentiated Type 

New issues iden.tified: Ctn staffed with cm Rasheedl1a about going ,vith tl1is cm to the park to meet Mul1ammad, 

Rasheedah said she would go \Vith this cm to the park behind l\l[aryvale Hospital to see if they could find 

I\1uhrurunad and introduced this cm to hi1n for the first tin1e. 

Recomm.ended Plans: 

1. Contact client 

Responsible party: Bryant BHT 

Con1pleted by: Ki1nberly Bryant BI:-I'f 

EDA: 10/27/2016 

Muhammad1tluhaymin 

Participru1ts 

"I participated in this case consultatio1i and the tlevelopment of these reco1nmendations." 

Name 

Electronica]lv Signed by: Kimberly Bryant .. BHT,/s/ 

Kimberly B1yant BHT 

Date/Time 

l0/27/2Q16 3:42PM 

Serv. Code 

Tl.0l.6HN53 

Electronically Signed by: Rasheedah Shaheed BPP /s/ 

Rasheedah Shaheed BPP 

10/28/2016 11:24 i\?-.1 T1016HN53 

Other Attendees 

R.asheedah, S_haheed (Co-vvorker) ' , 

Units Duration 

(minutes) 

l f, 

l l 

Sta11 End 

Time Tilne 

9:20am 9:22 Aivl 

9:20am 9:21 .AM 

Muhan1madMuhaymin Staffing note Rasheedah Shaheed BPP 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 124 of 179
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Muhan1mad.Muhaymin Staffing note Rasheedah Shaheed EPP 

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Contact Note 

Encounter Date: I 0/26/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

3:58 I>l\1 to 4:00 Pl\tl Dura.tion: 2 min 

Service code: T1016HN53 Units: 1 

Provider attempted to call guardian/sister. Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fa111ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

Cm called rvtussallina Muhammad g11ardian/sister and left a message infonning cm was send off the special 

assistant form. Civ[ explained in detail ,vhat the fon11 was about and why cn1 had to send it to OHR/f".\HCCCS in 

order to have his papen:vork on file and info1111 then1 who tvtuham.mad guardian ,:vas. C1v1 also infonned 

Mussallina this c1n \.vould need the pe1manent guardianship papenvork by ivionday and cn1 will be glad to meet 

her if need be. Ctn also informed wlussallina she could scan it and en1ail it to cm en1ail. Cm left her contact 

inf onnation incase she wanted to scan the documents. 

Cm will continue to reach out to guardian for guardianship papetwork. 

Indicators 

Electronicallv signed by: Kin1berly Brvant BHT Isl 

Provider Signature 

10/26/2016 04:27 PIV[ 

Date 

User Signature (person completing form): Electronically Sign.ed By: Kin1berly Bryant 

CIS ID: 099 

AHCCCS ID: aalll)335 

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Progress Note 

f:ncounter Date: 10/25120 16 11:02 AM to 11:56 AM Duration: 54 mi.n 

Service Code: T1016HN53 U11its: 4 

Patient Nan1e: Muhammad 

3099 

Muhaymin 

Patient 11): 

Provider Name:Rasheedah Shaheed BPP 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Data 

'fhis session was held at ()ffice with the following person(s) in attendance: 

Case Nianager, 

Discussion and Interventions: 

CtvI Shaheed met face to face ,vith !\1uhammad and his (3-uardian, :t\r1oslinah who is also his sister at W. NlcDowell 

clinic. Muhanunad ,vas dressed appropriately, hygiene good and mood anin1ated. He had shades on through the 

entire visit, therefore no eye contact was n1ade. 1vf uha011nad did not speak during the entire visit, however, he was 

responsive through hand jesters and head nods. Clv1 asked Iv1uhan1mad about his substance usage which he did not 

state \vhat drugs he uses aside fron1 marijuana. A5 C!vl spoke ,vith Muhan1111ad, his guardian \vould answer the 

questions to the best of her kt1owledge. 1\1uhamn1ad did write that he was interested in housing, counseling, and 

getting back on .i\lICCCS. CM shared with hitn and his guardian that Terros has a Benefits Specialist \vho can 

assist hin1 with getting on AHCCCS and food stamps. CM shared that J\1uhan1n1ad's CM, Ki1nberly can work with 

hi1n on getting counseling and he can speak to the housing Specialist about housing being that he is hon1eless and 

residing on the streets. CM asked Muhanunad for a contact number in which he provided 2510. CJvf 

asked ivluhannnad is he going to ans,ver the phone when CM calls him at which he stated that he would. 1'he 

guardian reports that Muhammad is not currently on any n1edications. CJvf advised the guardian that at 

Muhanu11ad1s nex1 appointment the Dr. will prescribe 111edications. CN1 provided Muhammad and his guardian with 

i1rf 01mation on what the clinic can provide Nluhammad and the support he \Votdd have from the clinical team. 

Muhan1111ad \Vas fairly responsive at this visit contrary to him not speaking a word. CNI walked J\1uhan1111ad and his 

guardian to the lobby and goy Muhammad rescheduled with Dr. Villalobos. Guardian stated tl1at she may not be in 

Phoenix for his next visit, ho\vever, \viii ask another relative to accon1pany hitn. 

Assessment 

Clt presented with sx ofUse of Drugs and .t\.lcohol, Reduced Ability to Carry ()ut Work and Social Roles. Barriers 

to progress are Homelessness, Substance Use. Clt's affect is Anitnated. Mood appears to be i\ppeared In1paired. 

CNI will staff tis visit with J\1uhatrunad's CJ\1. Kitnberlv. . - Client has no SI/HI Ideation. 

Progress 

Initial session. Established rapport. 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 1\1.R. #: Prog. Note 10/25/2016 12:40 PM Rashecdalt Shaheed 

Revision Date: 6/li00 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 127 of 179
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Plan 

This CM and CM, Kitnberly will attempt to meet vvith wluhammad this week in the conn11unity for well check and 

to take hitn a hygiene box. 

No homework given today. 

Electronicallv Signed Bv: Rasheedah Shaheed BPP 

Provider Signature 

Page 2/2 Pt. Name: MuhaYJnin, Jvluhan1n1ad 

Revision Date: 6/liOO 

10/25/2016 04:02 PM 

Date 

l\1.R. #: Prog. Note 10!25/201612:40 PM Rasheedah Shaheed 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 128 of 179
COP 015348

Tcrros 

Case Consultation N'ote 

Client N an1e: l\fuhanunadMu.l1avi1m1 ., l)OB: Date: 10/25/2016 

Client ID: 099 

Reason for Case (:onsultatio11: Coordination of care 

Curre11t Diagnosis: 295.90 Schizophrenia lJndifferentiated Type 

New issues iden.tified: Cl\1 Shaheed staffed with Kimberly, CM that this CM 1net ,vith Mul1ai1m1ad and his 

Guardian (sister) l\,1oslinah and completed a face to face. CM infom1ed Kimberly of Muhammad's next scheduled 

Dr. appointn1ent, updated I\1DR to include l\,,fuhanm1ad's cell nun1ber 2510, and his request tor a hygiene 

box. C1vl repo1ted that the Family Mentor is cu1Tently out of hygiene boxes, however, when received, Muhann11ad 

would like one. CJ\1 advised Kimberly that lviuham1nad ,vould like to see a PCP and get connected witl1 his 

AHCCCS. Niuhanm1ad also expressed an interest in attending counseling. Cl\1 updated phone nun1bers in NIDR. 

lviuham1nad is requesting housing. 

Recomm.ended Plans: 

1. CN1 will n1ake contact witl1 Nluhammad prior to his next scheduled Dr. appointn1ent 11/14/ 16@ 2pn1. 

Responsible party: Bryant BHT EDA: 11/04/2016 

Co1npleted by: I~.asheedah Shaheed BPP 

MuhammacL.\iluhaymin 

Participru1ts 

"I participated in this case consultatio,i and the 1/evelopment of these recomn,e,idations. " 

Name 

Electronically Signed by: Rasheedah Shaheed BPP /s/ 

Rasheedah Shaheed BPP 

Electronically Signed by: Kimberlv Bivant BHT /s/ 

Kirnberly Bryant BHT 

Dat:e/Thne Senr. Code Units Duration Sta11 

(minutes) Time 

End 

Tilne 

10/25(2016 12:50 PI\-1 T1016HN53 l 12:41 P~1 12:46 Pivf 

10/27/2016 3:42 P!\1 T1016HN53 l 5 12:41 P~1 12:46 PM 

Other i\ttendees 

Ki1nberly B1Y.,ant ( Case l\1anager) 

Muhan1madMuhaymin Staffing note Kimberly Bryant BHT 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 129 of 179
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Muhan1mad.Muhaymin Staffing note Kimberly Bryant BHT 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 130 of 179
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Psychiatric Progress Note 

Encounter Date: 10/25/2016 

Provider: 

Patient Name: 

Submitted Code(s): 

Lilliam Villalobos MD 

Muhammad Muhaymin 

Start Time: 10:00 AM End Time: 11 :00 AM 

EM Code: 99214 Unit 1 

Reason for Treatment: 

Presenting issues/Chief Complaint: I am fine 

Covering MD 

Age: 43 Years 

Patient is a 43 y/o, AA, male, came accompanied by sister, he is currently homeless, case was opened first 

at Magellan in 2010, intake paperwork not available for review, presented casually dress, mute, only 

answered question with a writen sentence, stated he need a medical marihuana card, a medical MD, 

housing, sister reported he has been using drugs: cannabis, questionable meth, homeless by choice, 

condition worsen after his father passed away, apparently they were very close to each other, when asked 

about symptoms he reported aud and visual hallucinations, some paranoia, denied S/H ideations. 

Sister had given Guardianship paperwork to CM to be fill out prior to Court Hearing Today. Sister wants to 

be his legal guardian. Paperwork completed during visit, original given to sister, copy to be included in MR. 

Recommendations: 

Plan reviewed: 10/25/2016 

Schedule appt for a Psych Eval. 

CM or CC to provide copy of Intake to MD. 

Sister to bring Legal Paperwork from the Court once she is the Legal Guardian. 

Evaluate the need for meds once patient returns for Psych Eval. 

Abstain from drugs. 

Refer to a PCP. 

Contact CM with any concerns. 

Practice Sleep Hygiene. 

Encourage compliance with Clinical Team recommendations. 

Encourage proper hydration, nutrition and exercise .. 

Contact the Crisis Line if pt becomes DTO/DTS. 

Follow up with PCP for Medical Concerns. Denied any now. 

RTC with Psychiatrist in 4 wks or as needed. 

RTC with RN for labs to be schedule or as needed for triage. 

Pagel of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 131 of 179
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Psychosocial stressors: Housing stressors are severe. 

Review of Systems: 

Initial Consultation 

Ears, Nose, Throat: Negative 

Constitutional: Negative 

Cardiovascular: Negative 

Endocrine: Negative 

Gastrointestinal: Negative 

Genitourinary: Negative 

Hematological: Negative 

Immunologic: Negative 

Musculoskeletal: Negative 

Respiratory: Negative 

Skin/Breast: Negative 

Eyes: Negative 

Neurological: Negative 

Psychiatric: Positive Additional Detail: psychotic 

Histories: 

Initial Consultation 

Past Medical History 

Past Medication: Has not taken meds in a long time. Treated while in jail but does not remember name. 

Developmental History: Normal 

History of injury, illness, and seizures: Denied. 

Meds Reported at Intake: 

Family History 

Mental illness in family: Cousin : Schizophrenia 

Substance abuse in family: Unknown 

Suicide attempts in family : Unknown 

Violence in family: Denied 

Medical problems in family : 

Other comments: 

Social History 

Client is homeless. Living situation is stressful. 

Mental Status: 

Client is a 43 year old, male. Dressed appropriately. Appears age and normal weight. Client is casually 

groomed. Oriented x 4. Level of alertness is normal. Eye contact is good. Client is mute. Mannerisms: 

posturing. Client is quiet. Thought processes: logical. Associations: logical. Stream of thought is 

unremarkable. Reports delusions of type: persecutory. Reports hallucinations of type: auditory, visual 

Page 2 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 132 of 179
COP 015352

Client is not DTS. Client is not DTO. Sleep: fair. Appetite: good. Mood: congruent. Affect: constricted. 

Fund of knowledge: good. Memory: good. Insight: poor. Judgement: poor. Concentration: good. 

Observed Gait: Steady. Muscle Strength and Tone appears: Normal. 

Client did not report danger to others (DTO). 

Client did not report danger to self (D'rS ). 

Medication Effectiveness and Side Effects: Client or Guardian reports experiencing no side effects to 

meds. 

Medical Data: 

No accidents, injuries or serious illnesses reported. 

Substance Use: 

Admitted to smoking cannabis 

Current Meds: 

Axis I - DSM -IV 

295.90 Schizophrenia lJndifferentiated Type 

Axis II: 

V71.09 No diagnosis on Axis II 

~i\.xis III: N()NE 

Axis Ill: NONE 

Axis IV: Problems with/related to housing, 

Axis V: NONE 

DSlVI -V 

F20_9 Schizophrenia 

Treatment Plan: No progress with Tx plan. Medications were not changed. 

The following were discussed with the client: Client or guardian understood and made an informed 

decision. 

Cit to be seen in 4 weeks. 

MOM ~ Problem Points 

Problem 

Psychotic 

Plan Desc 

No Plan 

Problem Detail 

New to Examiner 

Chonic Acute Workup 

NatureDesc 

Worsened 

Problem Notes 

Psychotic Chronic Additional Workup Planned Refer to SA tx. 

Medical Decision Making (data points): 

X Obtained history from someone other than the patient OR made decision to obtain records 

.J$ Reviewed and summarized records and obtained records and or had a discussion with another health care provider 

Risk: Moderate Risk 

Page 3 of 4 

Name: Muhanunad i\.1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 133 of 179
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Electronically Signed By: Lilliam Villalobos MD 

Docutnent generated and co1npleted 10/25/2016 11 :02 Afvl 

Page 4 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

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Contact Note 

Encounter Date: I 0/24/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Allyson Parsons BHT 

2:11 I>l\1 to 2:23 Pl\tl Dura.tion: 12 min 

Service code: T1016HN53 Units: 1 

Provider n1ade call to guardian. Contacted for coordination of care. CivI Parsons placed call to guardian to 

i1rfo1m her that client lvfuhamt11ad would no\V have a ne\V Clvf 

. Add Iaanos1s resse ct T o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

CM Parsons made call to client~ guardian oinfo1ming her that client would now have a new case manager 

Kin1berey Bryant. 1'his writer also was provided with client muha1nn1ed's cell phone# 2510. 

Staff case. 

Indicators 

Electronicallv signed by: . .\llyson Parsons BIIT Isl 

Provider Signature 

10/24/2016 0 5 :26 Pivl 

Date 

1.Jser Signature (person co1npleting fonn): Electronically Signed By: Allyson Parsons 

CIS ID: :,099 

AHCCCS ID: ~335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 135 of 179
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Tcrros 

Case Consultation N'ote 

Client N an1e: l\fuhanunadMu.l1avi1m1 l)OB: Date: 10/24/2016 ., 

Client ID: 099 

Reason for Case (:onsultatio11: Coordination of care 

Curre11t Diagnosis: 295.90 Schizophrenia lJndifferentiated Type 

New issues iden.tified: Cl\1 Parsons staffed Cn1 Bryant on her new client, cm Allyson gave c1n some paperwork on 

Muhann11ad and infom1ed cn1 CC David fron1 the act tean1 wanted to n1eet with hin1 to intervievv David for the Act 

tea1n. Ctn asked Allyson where Mul1ai1m1ad came from a11d cm Allyson was unsure but infbnned c1n C~c David 

111igllt. k11ow. 

Reconunend.ed J)lans: 

EDA: 10/24/2016 

Con1pleted by: ,L\.Uyson }'>arsons Blfr 

Muhammad1tluhaymin 

Participru1ts 

"I participated in this case consultatio1i and the tlevelopment of these reco1nmendations." 

Name 

Electroni~_aU.Y. .... $.wed by: A,U,vson Parsons .. ~J:ff l~L 

l\llyson Parsons BHT 

Electronically Signed by: Kimberlv Bivant BHT /s/ 

Kirnberly Bryant BHT 

Other Attendees 

kimbe:!:ky hry_ant 

Muhan1madMuhaymin 

Date/Time 

l0/24/2Q16 5:29PM 

l l/01/2016 7:39 Aivf 

( Case l\1anager) 

Staffing note 

Serv. Code Units Duration 

(minutes) 

Tl.0l.6HN53 l ~ 

T1016HN53 l 5 

Kimberly Bryant BHT 

Sta11 End 

Time Tilne 

5:27 ... Pivl 5:32 PM 

5:27 Pivl 5:32 P~1 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 136 of 179
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Muhan1mad.Muhaymin Staffing note Kimberly Bryant BHT 

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Contact Note 

Encounter Date: I 0/24/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Kimberly Bryant BHT 

1:17 I>l\1 to 1:25 Pl\tl Dura.tion: 8 min 

Service code: T1016HN53 Units: 1 

Provider n1ade call to Nlussallina guardian. Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

Case Managen1ent: activities 1nay include assisting, maintaining, and 1nonitoring covered services~ finding 

necessary resources to meet basic needs, coordinating care with fa111ily and other agencies involved, outreach 

and folto,v up, and other activities as needed. 

Cm called and spoke ,vith Mul1ai1m1ad sister who is also his guardian and ,vas info11ned she needed the 

pape1work to get full guardianship for ton1orrow. Cn1 info1med Mussallina that Muhammad would need to 

come to the his appointment tomon:ow at 1 Oam in order for the doctor to fidl out the paperwork. ivf ussallina 

infom1ed cn1 that Muhannnad stay in the park on 51 st Ave in Maryvale area. Cm asked Mussallina if 

lviuham1nad ,vould l,e needing a ride. Mussallina said she would be hin1 in. Cm informed Mussallina she would 

see the1n ton1on·ow for a f2f and to set a time to complete his assess1nent and ISP. 

Client scheduled. 

Indicators 

Electronicallv signed by: Kin1berly Brvant BHT /s/ 

Provider Signature 

10/24/2016 01: 43 PIV[ 

Date 

User Signature (person completing form): Electronically Sign.ed By: Kin1berly Bryant 

CIS ID: 099 

AHCCCS ID: aalll)335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 138 of 179
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Progress Note 

f:ncounter Date: 10/14/2016 02:26 P~I to 03:21 PM Duration: 55 mi.11 

Service Code: T1016HN53 U11its: 4 

Patient Nan1e: 

Patient 11): 

Muhammad 

3099 

Muhaymin 

Provider Name:Allyson Parsons BHT 

. Add Iaanos1s resse d T d o av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Data 

New OR Continuing 

Continuing 

'fhis session was held at ()ffice with the following person(s) in attendance: 

Case ivianager, Guardian Ad Litem, 

Discussion and Interventions: 

CtvI Parsons met witl1 Guardian of Muhru1uned in lobby of clinic and spoke about ho,v he has been doing. 

Guardian stated he was outside in car and CI\.1 asked if it \vould be alrigl1t to introduce herself and perhaps build 

somewhat of a rapport and if nothing else "break the ice." Gt1ardian escorted tl1is CI\,1 outside and and to tl1e vehicle 

CLient ivluhammed was sitting in. CM P Arsons introduced herself and shook hands with client as she proceeded to 

exl)lain her ro]e a5 his case manasger to both guardian and client. Client was receptive and cordial to this CM and 

guardian, cn1 and client all agreed to schedule a ind appointment and client ,vould attend with either guardian or 

Cl\11. Cl\11 Parsons thrulk.ed both guardian and client ru1d cklient Muhan1n1ed was looking forward to ne:\.1111eeting 

and getting to know the clinoic and services available. CM Parsons assisted guardian in scheduling appoint1nent for 

Cl.,ient. 

Assessment 

Clt presented with sx of Pleasant. Barriers to progress arc Lack of housing. Clt's affect is smiling, happy. J\1ood 

appears to be euphoric. 

Client has no SI/HI Ideation. 

Progress 

Remarkable Progress. 

Plan 

Cl\11 Parsons confirmed Psych evaluation scheduled and will follow up ,vith guardiru1 and client as a reinder of 

upcoming appointment 

No homework given today. 

Electronicallv Signed Bv: .... Allyson Parsons BHT 

Provider Signature 

Page 1/2 Pt. Name: Muhayrnin, :rvtuhan1n1ad 

Revision Date: 6/li00 

10/14/2016 05:41 PM 

Date 

1\1.R. #: Prog. Note 10/14/2016 .5:30 Pl\1 Allyson Parsons 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 139 of 179
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Page 2/2 Pt. Name: MuhnYJnin, Jvluhan1n1ad l\1.R. #: Prog. Note 10!14/2016 5:30 Pl\.1 Allyson Parsons 

Revision Date: 6/liOO 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 140 of 179
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Contact Note 

Encounter Date: I 0/14/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Amy Beard BHT 

3:22 I>l\1 to 3:23 Pl\tl Dura.tion: 1 min 

Service code: A01104 U11its: 1 

Provider provided bus pass to client. Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

Provided regular fare bus pass, #L3 l -721700 

Indicators 

Electronically signed by: A111y Beard BHT Isl 

Provider Signature 

·user Signature (person completing form): Electronically Signed By: Amy Beard 

CIS ID: 099 

AHCCCS ID: ~335 

New OR Continuing 

Continuing 

10/31/2016 02:46 PM 

Date 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 141 of 179
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Contact Note 

EncounterDate: 10/11/2016 11:33 AM to 11 :34 ,4M No billing for service 

Patient Name: Muhammad Muhaymin 

Provider Name: 1\my Beard BH1' 

Provider received e-mail from . Contacted for coordination of care. 

D 1annos1s Add resse d T d o av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

From: ACT Refen·al [mailto:Office365@messaging.microsoft.con1] 

Sent: ·ruesday, Clctol,er II, 2016 11:33 AM 

New OR Continuing 

Continuing 

To: David J. \Valker <David.JWalker@te1Tos.org:•; l\1ichelle Shea LCSW <l\1ichelle.Shea@ten·os.org:> 

('c: 1'ho,nas !3ohanske <"I'ho1nas.Bohanske(g)te1Tos.org>; Julia l'v1atthies <Ju1ia.l'v!atthies@te1Tos.org>; ,'\("!' 

Referral <,A.CTReferrals@n1ercymaricopa.org> 

Subject: Re: [SEND SEClJRE] C'PI< ,c\('1' Refen·al \V l'v1cdo,vell l\1M 

'fhank you for the update, please keep me posted on the last atte1npt. 

Devonne 

Fro1n: David J. Walker ,:David.J\Valker(g)terros.org> 

Sent: lv!onday, ()ctober 10, 2016 4:44:16 Plvl 

To: ACT Referrals; lv1ichelle Shea LCSW 

Cc: 'fhomas Bohanske; Julia Mattl1ies 

Subject: RE: [SEND SECURE] CPR ACT Referral W Mcdowell lv1M 

Yes, I have n1ade 2 atten1pts to screen this member. On 9/29/16 I went to the residence vvhere the guardian 

resides and was infon11ed by the roommate that the guardian ,vas not there and that she vvould in101m her that I 

came over. On I 0/7 I 16 at On I 0/7 /16 at 9:00a,n I met with the guardian and we went to the park where the 

n1ember resides. lJpon arrival at the park the mother/guardian and I vvere not able to locate the me1nber. 111e 

members mother and I agreed to attempt to locate the member again this vveek in the park for another atten1pt to 

sereen. 111e mother reported to me that she had spoken to him on 10/6 ki1e,v that we were con1i11g at 9:00am. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 142 of 179
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The 111other reported that I should not go ,vithout her as he can get aggressive and she feels he might if so1neone 

he doesn't kno,v goes to the park unannounced. In. addition he had an appointn1ent \vith the supportive tea111s Dr. 

here at the West l\licDowell on 10/3/16 and he "no sho,;ved" that appointn1ent as well. 

David J. Walker 

Clinical Coordinator 

5030 \V. lVIcDowell Rd. o Phoenix, AZ 85035 

P: 602-685-6825 

CC will send info11nation to C11 Parsons so she is aware of the atten1pts to contact. 

Indicators 

Electronically signed by: A111y Beard BHT Isl 

Provider Signature 

·user Signature (person completing form): Electronically Signed By: Amy Beard 

CIS ID: 099 

AH(:c:cs IL): aall:)335 

10/11/2016 12:59 PM 

Date 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 143 of 179
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Contact Note 

Encounter Date: I 0/03/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Rasheedah Shaheed BPP 

2:32 I>l\1 to 2:58 Pl\tl Dura.tion: 26 min 

Service code: T1016HN53 Units: 2 

Provider n1et \Vith , guardian at Office. Contacted for coordination of care . 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

C:tvl Shaheed n1et with I\,fussallinah, Muhammad's sister/guardian due to her conce1ns about Mul1ai1m1ad being 

hotneless and not taking his n1edications \Vhich is causing hin1 to be more sympton1atic. Nlussallinah reports that 

she took off work to acco1npany Muha1nn1ad to his appoint1nent today, however, he declined to co1ne to the 

clinic reportedly stating "I'm not sure what \vill happen bet,veen 111on1as and McDowell if I get in the car." 

I\1ussa1linah stated that she received this 1nessage to mean she may not be safe transporting l\lluhan1mad. She 

reports that she gave Muhammad money for something to eat as she usually take him out to eat but did not feel 

comfortable today doing so. C:t\1 provided supportive and active listening. Cl\11 advised Mussallinah that this 

CM will staff her concen1s in morning meeting and see ifl\1Iuhanm1ad would qualify to be on tl1e act team due 

to him requiring m.ore intense services at this time. l\!Iussallinah reports that she cannot take off work regularly 

to bring :tvf uhammad to his appointn1ents and was wondering how the clinical team cru1 help her get 

lvfuham1nad to his appointments. Civl stated that som.cone fro1n the team ,vill go to where she reports 

l\1uhat11mad to be living which is in the park by Mal)rville Hospital. Cl\1 advised Mussallinah that the clinical 

team will n1ake all attet.npts to engage l\1Iuhann11ad in services and set him up to be able to take his n1edications 

daily. At this time Mussallinal1 obtained her te1nporary guardianship papers fron1 her car so this Cl\1 could 

tnake a copy for l\!luhanunad's file. Cl\!I tnade the copy and returned the original back to Mussallinal1. Cl\!1 

obtained lviussallinah contact number 786 and stated that someone vvill be contacting her to update 

her on the whereabouts ofMuhru111nad and ifhe was re-engaged back with services on his part. 

Client scheduled. 

Indicators 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 144 of 179
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Electronicallv sigt1ed by: Rasheedah Shaheed BPP /s/ 

Provider Signature 

10/04/201611:32 AM 

Date 

1.Jser Signature (person co1npleting fonn): Electronically Signed By: Rasheedah Shaheed 

CIS ID: 099 

AHCCCS ID: ~335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 145 of 179
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Contact Note 

Encounter Date: 09/28/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Allyson Parsons BHT 

4:22 I>l\1 to 4:29 Pl\tl Dura.tion: 7 min 

Service code: T1016HN53 Units: 1 

Provider received call from guardian. Contacted for coordination of care. Cl\1 received call frotn clients 

guardian confirming scheduled 11D appointment on 11onday, October 3rd at 11am . 

. Add Iaanos1s resse ct T o d av: 

Diagnosis Diagnosis Description New OR Continuing 

F20.9 Schizophrenia Continuing 

CM P1\rsons took call fron1 clients guardian confin11ing clients appointn1ent \Vith MD on October 3rd. 

C~lient scheduled. 

Indicators 

Electronically signed by: Allyson Parsons BHT /s/ 

Provider Signature 

10/11/2016 03:49 PM 

Date 

User Signature (person completing form): Electronically Signed By: Allyson Parsons 

CIS ID: 099 

AH(:c:cs IL): aall:)335 

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Contact Note 

Encounter Date: 09/23/2016 

Patient Name: Muhammad Muhaymin 

Provider Nan1e: Amy Beard BHT 

4:38 I>l\1 to 4:39 Pl\tl Dura.tion: 1 min 

Service code: T1016HN53 Units: 1 

Provider provided bus pass to client. Contacted for coordination of care. 

. Add Iaanos1s resse dT o d av: 

Diagnosis Diagnosis Description 

F20.9 Schizophrenia 

From: i\tny Beard 

Sent: Friday, Septen1ber 23, 2016 4:38 PM 

~ro: Julia Matthies <Julia.Matthies(l~ten·os.org> 

Subject: Dx needed, see belo\v 

Fron1: i\n1v Beard .. Sent: Friday, Septeinber23, 2016 4:13 P~11 

To: Allyson Parsons <:1~lyson.Parsons(@ten·os.org> 

Su~iect: F\V: ne\v refe1Ta.l-tv1uham.mad 

/\Hyson, 

New OR Continuing 

Continuing 

I atn assigning I\i1t1ha1runad Muhayn1in to on your caseload. It is docutnented he has a Guardian, his sister, 

1\1ussallina I\1uhaymin 786, and he is homeless at this tin1e. I will be requesting an MD appoint111ent 

in 7 days, so you can give that appointn1ei1t to tv1uha1nn1ad and his sister, as she tnay know \vhere to find hin1. 

Per report in the Core assessn1ent: i\ll of the infonnation gathered below vvas fron1 the sister/guardian. BHR's 

sister reported he is primarily psychotic, delusional and having i\ VH and is una\vare of tnood sytnpton1s, 

anxiety or what substances he n1ay use. Given \vhat is 

known, the Blfll appears to meet criteria for F20.9 Schizophrenia. 

Please contact his sister and give the Docto Please contact his sister and give the Doctor's appointn1ent, 

September 30tl1 from l lru11-12pn1 and I will request it to be scheduled. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 147 of 179
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Thanks, 

Amy Beard 

Clinical Coordinator 

5030 V\T l\!IcDowell Rd, Ste 16 o Phoenix, AZ 85035 

P: 602-285-6819 

Indicators 

Electronicallv signed by: A111y Beard BHT Isl 

Provider Signature 

·user Signature (person completing form): Electronically Signed By: Amy Beard 

CIS ID: 099 

AHCCCS ID: 35 

09/27/2016 08:30 Al\,1 

Date 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 148 of 179
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Psy~chiatric E,1aluation Note 

Encounter Date: 12/05/2016 

Provider Name: Lilliam Villalobos MD 

Patient Name: Muhammad Muhaymin 

Submitted Code(s): 

Start Time: 10:24 AM End Time: 11 :00 AM 

Non EM Code: 90/92 Unit: 1 

Referred by: 03 - Other Behavioral H Ith Provider 

Sources of information: Client, chart, 

Reason for Visit 

Presenting issues/Chief Complaint: I need a massage. 

Age: 43 Years 

History of Presenting Illness: Patient is a 43 y/o~ AAf malet he came accompanied by stepmotherJ homeless 

by choice, cames accompanied by step mother and sister, they brought some paperwork for GuardianshipJ 

family reported pt~s symptoms started after his father passed away in 2006$ patient was very close to his father, 

patient started to have aud hall, he was arrested for tresspassingf jade walking1 first time he spend 13 days in 

jail, did not take any medicationst after he got out of jail he started to decompensate , in 2007 he spend 1 year 

in jail~ reasons why he was arrested were not clears multiple areest for different reasons. 

Treated in the past with Risperdal1 Wellbutrim SR~ SeroqueL Did not like Risperdal stated he felt agitated on it 

Seroquel was making him tired, poor historian, family does not have enough information, 

Psychotic symptoms: Aud hall, visual hall, paranoia, periods of being mute, alternating with agitation, 

disorganized thought process. 

Depressive symptoms: Sa.d, most of the time. 

Behaviors worsen with drug use. Did not specify drugs use. 

Presented disorganized~ periods of thought blocking, paranoia, guarded, loose of associations. 

Recommendations: 

Plan reviewed: 12/5/2016 

Family will confirm what medication worked in the past.. 

CSPMP reviewed. No opiates rx'ed. 

PCP Coordination to be done as needed. 

Continue to provide Supportive Therapy. 

Contact Case Manager with any concerns. 

Practice Sleep Hygiene~ 

Continue compliance with Clinical Team recommendations. 

Encourage proper hydration~ nutrition and exercise. Regular Diet. 

Risk factor reduction: Avoid stressful situations; contact Clinical Team with any concerns. 

Contact the Crisis Line if he becomes DTO/DTS. 

Page 1 of 4 Pt. 1\J arne: Muha.mm.ad r..-1uhav:min ~ 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 149 of 179
COP 015369

Follow up with PCP for Back problems. 

RTC with Psychiatrist in 6--8 wks or as needed. 

RTC with RN for labs or as needed for triage. 

Symptoms of Schizophrenia include: haUucinationsl delusions~ disorganized speech, grossly disorganized 

behavior, poverty of speechl flattened affect, poor hygiene1 social isolation. 

Current treatment: Client/Guardian reports no current behavioral health treatment. 

Psychiatric Treatment 

History of previous treatment: Psychiatric medication .. 2007. Treatment was helpful. 

Psychiatric hospitalizations: Client/Guardian reports no hospitalizations. 

Past medications: Has not taken meds in a long time. Treated while in jail but does not remember name. 

History of dangerousness to self and/or others: Past DTS/DTO: Self-injurious behaviors: cuttingl none 

past month. Suicidal attempts: 2006- c cu cut cutt cutti cuttin cutting 

Bia:th=. Devel,oument1 and ,Educati~n 

Developmental history: NormalClient was full term. No in utero exposure to drugs, alcohol or nicotine 

reported. No postnatal complications reported. Raised by Stepmother. and Father. Developmental milestones 

were reportedly reached on time. Walked within normal limits. Talked within normal limits. Toilet training 

within normal limits. 

History of Abuse/Neglect/Trauma: No physical, sexual or emotional abuse reported. 

Education: Last grade completed was second year of college. 

Employment history: Unemployed 

Military history: No history. 

Medical Historx 

Review of Systems: 

Initial Consultation 

Earst Nose, Throat: Negative 

Constitutional: Negative 

Cardiovascular: Negative 

Endocrine: Negative 

Gastrointestinal: Negative 

Genitourinary: Negative 

Hematological: Negative 

Immunologic: Negative 

Musculoskeletal: Negative 

Respiratory: Positive Additional Detail: asthma 

Skin/Breast: Negative 

Eyes: Negative 

Neurological: Negative 

Psychiatric: Positive Additional Detail: psychotic 

Vitals 

Medication allergies: No known drug allergies. 

Client/Guardian reports head injuries with loss of consciousness. Reports loss of consciousness: R.eports no 

history of seizures. Client denies Glaucoma. Last eye exam - none . Recommended client have annual eye 

exam. Reports no current treatment of chronic illness. Client/Guardian denies any major surgical history. 

Page 2 of 4 Pt. 1\J arne: Muha.mm.ad r..-1uhav:min ~ 

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Mental illness in family: Cousin : Schizophrenia Substance abuse in family: Unknown Suicide attempts in 

family: Unknown Violence in family: Denied Medical problems in family: Mother died 

Father died 

Current Living Arrangements and Support 

Client is homeless. Living situation is stressful. 

Legal History 

Past legal issues are jail, No current legal issues reported. 

Alcohol and Substance Abuse History 

Client acknowledges having substance abuse problems. Client reports that others have said they have a 

substance abuse problem. 

Admitted to smoking cannabis 

Current Medications 

Client reports no current medications, including vitamins, herbal and over the counter medications. 

Mental Status Exam 

Client is a 43 year old, male. Dressed appropriately. Appears age and normal weight. Client is disheveled. 

Client is casually groomed. Oriented x 4. Level of alertness is normal. Eye contact is good. Speech quantity 

is normal with normal rate and normal amplitude. Client has no mannerisms of note .. Thought processes: 

blocking. Associations: logical. Stream of thought is blocked. Reports delusions of type: persecutory. 

Reports hallucinations of type: auditory, visual 

Sleep: continuity disturbance. Appetite: good. Mood: congruent. Affect: blunted. Fund of knowledge: 

good. Memory: good. Insight: fair. Judgement: poor. Concentration: fair. Judgement: fair. 

Observed Gait : Steady. Muscle Strength and Tone appears: Normal. 

Client did not report danger to self (DTS). 

Client did not report danger to others (D'l'O). 

Axis I - DSl\·f. -IV 

295.10 

305.20 

Axis II: 

V71.09 

Axis III: 

Axis Ill: 

Axis IV: 

Axis V: 

Schizophrenia Disorganized Type 

Cannibus Abuse 

No diagnosis on A."{is II 

30 Chronic Pulmonary Disorders 

30 Chronic Pulmonary Disorders 

Problems with/related to housing, 

45 

Plan for work up and treatment 

l)SJ\11-V 

F20.9 

Fl2.10 

Schizophrenia 

Cannabis use disorder, IVfild 

Discussion: Discussed diagnosis and treatment options. Client/Guardian advised of after hours crisis line 

number: {Psych_eval_pl. Risks of declining treatment discussed. Client/Guardian understood and made 

informed decision. Client/Guardian given business card with clinic phone number and instructed to call if 

there are problems or questions prior to next visit. 

Page3of4 Pt. Name: Muhammad l\.1uhaymin 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 151 of 179
COP 015371

Next appointment: 6 weeks 

MOM ... Problem Points 

Problem 

psychosis 

Problem 

psychosis 

Plan Desc 

No Plan 

Problem Detail 

New to Examiner 

Chonic Acute Workup 

Chronic No Additional Workup 

Medical Decision Making (data points): 

NatureDesc 

Worsened 

Notes 

X Obtained history from someone other than the patient OR made decision to obtain records 

_x Rev1ev,ed and summarized records and obtained records and or had a discussion with another health care provider 

Risk: Moderate Risk 

Electronically Signed By: Lilliam Villalobos MD Date 12/05/2016 

Page 4of4 Pt. 1\J arne: Muha.mm.ad r..-1uhav:min ~ 

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lnspbung Change 

fo'lUfe 

Psychiatric Progress Note 

Encounter Date: 12/05/2016 

Provider: 

Patient Name: 

Submitted Code(s): 

Lilliam Villalobos MD 

Muhammad Muhaymin 

Start Time: 10:24 A~A End Time: 11 :00 AM 

Non EM Code: 90792 Unit: 1 

Open in errorr 

Pagel of 1 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

No billing for service 

Age: 43 Years 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 153 of 179
COP 015373

lnspbung Change 

fo'lUfe 

Psychiatric Progress Note 

Encounter Date: 11/14/2016 

Provider: 

Patient Name: 

Submitted Code(s): 

Lilliam Villalobos MD 

Muhammad Muhaymin 

Start Time: 02:00 PM End Time: 02:30 PM 

EM Code: 99214 Unit 1 

Reason for Treatment: 

Presenting issues/Chief Complaint: I am as ok as I can be. 

Age: 43 Years 

Patient came accompanied by Stepmother, she brought some paperwork for the Guardianship, we 

discussed that her daughter was given the same paperwork filled out last appt, patient remains homeless, 

presented casually dressed, clean, had his dog with him, responded questions when asked, disorganized, 

moderate FOi, LOA, when asked if he was sleeping he said 'earth'\ appetite ok, denied any S/H ideations, 

questionable hall, did not answer accordingly. Drug use hx, drug of choice cannabis. 

Recommendations: 

Plan reviewed: 11/14/2016 

Schedule appt for a Psych Eval. 

CSPMP reviewed. No opiates rx'ed. 

Once Psych Eval completed I will consider rx meds. 

Continue to provide Supportive Therapy. 

Contact Case Manager with any concerns. 

Practice Sleep Hygiene. 

Continue compliance with Clinical Team recommendations. 

Encourage proper hydration, nutrition and exercise. Regular Diet. 

Risk factor reduction: Avoid stressful situations; contact Clinical Team with any concerns. 

Contact the Crisis Line if he becomes DTO/DTS. 

Follow up with PCP for Medical Concerns. Denied any now. 

RTC with Psychiatrist in 4 wks or as needed. 

RTC with RN for labs or as needed for triage. 

Psychosocial stressors: Housing stressors are severe. 

Review of Systems: 

Reviewed, NO changes 

Ears, Nose, Throat: Negative 

Pagel of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 154 of 179
COP 015374

Constitutional: 

Cardiovascular: 

Endocrine: 

Gastrointestinal: 

Genitourinary: 

Hematological: 

Immunologic: 

Musculoskeletal: 

Respiratory: 

Skin/Breast: 

Eyes: 

Neurological: 

Psychiatric: 

Histories: 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Negative 

Positive Additional Detail: psychotic 

Reviewed with NO Changes 

Past Medical History 

Past Medication: Has not taken meds in a long time. Treated while in jail but does not remember name. 

Developmental History: Normal 

History of injury, illness, and seizures: Denied. 

Meds Reported at Intake: 

Family History 

Mental illness in family: Cousin : Schizophrenia 

Substance abuse in family: Unknown 

Suicide attempts in family : Unknown 

Violence in family : Denied 

Medical problems in family: Mother died 

Father died 

other comments: 

Social History 

Client is homeless. Living situation is stressful. 

Mental Status: 

Client is a 43 year old, male. Dressed appropriately. Appears age and normal weight. Client is 

well-groomed. Oriented to situation, place, person. Level of alertness is normal. Eye contact is good. 

Speech quantity is diminished with slow rate and diminished amplitude. Client has no mannerisms of 

note .. Thought processes: tangential. Associations: very loose. Stream of thought is tangential. Reports 

no delusions.. No hallucinations reported. 

Client is not DTS. Client is not OTO. Sleep: fair. Appetite: good. Mood: congruent. Affect: flat. Fund of 

knowledge: fair. Memory: fair. Insight: poor. Judgement: poor. Concentration: poor. 

Observed Gait : Steady. Muscle Strength and Tone appears: Normal. 

Client did not report danger to otl1ers (DTO). 

Client did not report danger to self (D'fS). 

Page 2 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 155 of 179
COP 015375

Medication Effectiveness and Side Effects: Client or Guardian reports experiencing no side effects to 

meds. 

Medical Data: 

No accidents, injuries or serious illnesses reported. 

Substance Use: 

Admitted to smoking cannabis 

Current Meds: 

Axis I - DSl\11 -IV 

295. 90 Schizophrenia UnditTerentiated Type 

Axis II: 

V71.09 

Axis III: 

Axis Ill: 

Axis IV: 

Axis V: 

NONE 

NONE 

No diagnosis on Axis II 

Problems with/related to housing, 

NONE 

DSM-V 

F20.9 Schizophrenia 

Treatment Plan: No progress with Tx plan. Medications were not changed. 

The following were discussed with the client: Client or guardian understood and made an informed 

decision. 

Cit to be seen in 4 weeks. 

MOM - Problem Points 

Problem 

Disorganized 

Problem 

Disorganized 

Plan Desc 

No Plan 

Problem Detail 

New to Examiner 

Chonic Acute Workup 

Chronic No Additional Workup 

Medical Decision Making (data points): 

NatureDesc 

Worsened 

Notes 

Needs psych eval 

1 Obtained history from someone other than the patient OR made decision to obtain records 

~ Revie\Ned and summarized records and obtained records and or had a discussion with another health care provider 

Risk: Moderate Risk 

Electronically Signed By: Lilliam Villalobos MD 

Document generated and completed 11/14/2016 02:36 PM 

Page 3 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

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Page 4 of4 

Name: Muhanunad i\-1uhayinin ClS ID: ....,099 

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COP 015377

lnspbung Change 

fo'lUfe 

Psychiatric Progress Note 

Encounter Date: 10/25/2016 

Provider: 

Patient Name: 

Submitted Code(s): 

Lilliam Villalobos MD 

Muhammad Muhaymin 

Start Time: 10:00 AM End Time: 11 :00 AM 

EM Code: 99214 Unit 1 

Reason for Treatment: 

Presenting issues/Chief Complaint: I am fine 

Covering MD 

Age: 43 Years 

Patient is a 43 y/o, AA, male, came accompanied by sister, he is currently homeless, case was opened first 

at Magellan in 2010, intake paperwork not available for review, presented casually dress, mute, only 

answered question with a writen sentence, stated he need a medical marihuana card, a medical MD, 

housing, sister reported he has been using drugs: cannabis, questionable meth, homeless by choice, 

condition worsen after his father passed away, apparently they were very close to each other, when asked 

about symptoms he reported aud and visual hallucinations, some paranoia, denied S/H ideations. 

Sister had given Guardianship paperwork to CM to be fill out prior to Court Hearing Today. Sister wants to 

be his legal guardian. Paperwork completed during visit, original given to sister, copy to be included in MR. 

Recommendations: 

Plan reviewed: 10/25/2016 

Schedule appt for a Psych Eval. 

CM or CC to provide copy of Intake to MD. 

Sister to bring Legal Paperwork from the Court once she is the Legal Guardian. 

Evaluate the need for meds once patient returns for Psych Eval. 

Abstain from drugs. 

Refer to a PCP. 

Contact CM with any concerns. 

Practice Sleep Hygiene. 

Encourage compliance with Clinical Team recommendations. 

Encourage proper hydration, nutrition and exercise .. 

Contact the Crisis Line if pt becomes DTO/DTS. 

Follow up with PCP for Medical Concerns. Denied any now. 

RTC with Psychiatrist in 4 wks or as needed. 

RTC with RN for labs to be schedule or as needed for triage. 

Pagel of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 158 of 179
COP 015378

Psychosocial stressors: Housing stressors are severe. 

Review of Systems: 

Initial Consultation 

Ears, Nose, Throat: Negative 

Constitutional: Negative 

Cardiovascular: Negative 

Endocrine: Negative 

Gastrointestinal: Negative 

Genitourinary: Negative 

Hematological: Negative 

Immunologic: Negative 

Musculoskeletal: Negative 

Respiratory: Negative 

Skin/Breast: Negative 

Eyes: Negative 

Neurological: Negative 

Psychiatric: Positive Additional Detail: psychotic 

Histories: 

Initial Consultation 

Past Medical History 

Past Medication: Has not taken meds in a long time. Treated while in jail but does not remember name. 

Developmental History: Normal 

History of injury, illness, and seizures: Denied. 

Meds Reported at Intake: 

Family History 

Mental illness in family: Cousin : Schizophrenia 

Substance abuse in family: Unknown 

Suicide attempts in family : Unknown 

Violence in family: Denied 

Medical problems in family: Mother died 

Father died 

Other comments: 

Social History 

Client is homeless. Living situation is stressful. 

Mental Status: 

Client is a 43 year old, male. Dressed appropriately. Appears age and normal weight. Client is casually 

groomed. Oriented x 4. Level of alertness is normal. Eye contact is good. Client is mute. Mannerisms: 

posturing. Client is quiet. Thought processes: logical. Associations: logical. Stream of thought is 

unremarkable. Reports delusions of type: persecutory. Reports hallucinations of type: auditory, visual 

Page 2 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 159 of 179
COP 015379

Client is not DTS. Client is not DTO. Sleep: fair. Appetite: good. Mood: congruent. Affect: constricted. 

Fund of knowledge: good. Memory: good. Insight: poor. Judgement: poor. Concentration: good. 

Observed Gait: Steady. Muscle Strength and Tone appears: Normal. 

Client did not report danger to others (DTO). 

Client did not report danger to self (D'rS ). 

Medication Effectiveness and Side Effects: Client or Guardian reports experiencing no side effects to 

meds. 

Medical Data: 

No accidents, injuries or serious illnesses reported. 

Substance Use: 

Admitted to smoking cannabis 

Current Meds: 

Axis I - DSM -IV 

295.90 Schizophrenia lJndifferentiated Type 

Axis II: 

V71.09 No diagnosis on Axis II 

~i\.xis III: N()NE 

Axis Ill: NONE 

Axis IV: Problems with/related to housing, 

Axis V: NONE 

DSlVI -V 

F20_9 Schizophrenia 

Treatment Plan: No progress with Tx plan. Medications were not changed. 

The following were discussed with the client: Client or guardian understood and made an informed 

decision. 

Cit to be seen in 4 weeks. 

MOM ~ Problem Points 

Problem 

Psychotic 

Plan Desc 

No Plan 

Problem Detail 

New to Examiner 

Chonic Acute Workup 

NatureDesc 

Worsened 

Problem Notes 

Psychotic Chronic Additional Workup Planned Refer to SA tx. 

Medical Decision Making (data points): 

X Obtained history from someone other than the patient OR made decision to obtain records 

.J$ Reviewed and summarized records and obtained records and or had a discussion with another health care provider 

Risk: Moderate Risk 

Page 3 of 4 

Name: Muhanunad i\.1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 160 of 179
COP 015380

Electronically Signed By: Lilliam Villalobos MD 

Docutnent generated and co1npleted 10/25/2016 11 :02 Afvl 

Page 4 of 4 

Name: Muhanunad i\-1uhayinin ClS ID: --,099 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 161 of 179
COP 015381

Terros 

Psychiatric No Show Note 

Encounter Date: 10/03/2016 

Patient Name: 

Muhaymin 

Provider Name: Lynnette Hjalmervik NP 

No billing for service 

Muhammad 

No call from cit/guardian. NO SHOW for new member psychiatric evaluation. 

17888B9D-05A7-4587-B843-592FC89E5463 

Signature 

:tvL R. #: Lynnette Hjalmervik 

Revision Date: 6/1 /00 

10/11/2016 09:08 AM 

Date 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 162 of 179
COP 015382

:tvL R. #: Lynnette Hjalmervik 

Revision Date: 6/1 /00 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 163 of 179
COP 015383

:tvL R. #: Lynnette Hjalmervik 

Revision Date: 6/1 /00 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 164 of 179
COP 015384

:tvL R. #: Lynnette Hjalmervik 

Revision Date: 6/1 /00 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 165 of 179
COP 015385

:tvL R. #: Lynnette Hjalmervik 

Revision Date: 6/1 /00 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 166 of 179
COP 015386

Terros 

Error Correction for Muhammad Muhavmin ., 

Allyson Parsons 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 167 of 179
COP 015387

accidently open extra 

Terros 

Error Correction for Muhammad Muhavmin ., 

Kimberly Bryant 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 168 of 179
COP 015388

Terros 

Error Correction for Muhammad Muhavmin 

by Lilliam ViHalobos MD 

by Lilliam Villalobos MD 

Lilliam Villalobos 

Open in error 

., 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 169 of 179
COP 015389

Terros 

Error Correction for Muhammad Muhavmin ., 

Allyson Parsons 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 170 of 179
COP 015390

l.rupin.in9 Cha.119e 

fo'1 life Behavioral Health Service Plan 

N ain.e: tv1uhanm1ad Muhay1nin DOB: 

CIS ID#: 099 StateID #: --0335 

Prograin: Supportive Today's Date: 12/12/2016 

lndi,riduals at Service Plaiming 1\lleeti11g: Case rvianger Ki111berly Bryant, Clietn Muhammad I\1uhaymin, Guardian 

lvfussallina I\1uhayn1in 

Recovery Goal/Person-FanliJy Vision: Living Goal: I want own apartment. 

Lean1i11g/Working Goal: I want to work part-time to earn money. 

Social Goal: I want attend community groups. 

Health Goal: I want to visit \Vith PCP yearly for routine check-up. 

Reaso11s I want to participate iI1 this program/activity: . I\1uhan1111ad is wanting help \Vith housing, n1edications 

111anagement, case n1anagement. 

Cli.ent/family say tl1e following 11eeds to l1ave happened ht order for th.en1 to feel ready to leave servi,~es: 

I\1uhan1111ad needs to learn how to manage his syn1ptoms and continue to stay stable. 

Does the client want anyone involved in treatment at tins time? (i Yes(~ No 

Family Member Name Relationship Involvement 

Mussallina Muhaymin sister All 

J>erso11 's Strengths 

Type 

Individual 

Individual 

Strength 

J\1uha111n1ad can cook and clean 

Muhammad car drive 

Evidenced By 

J\1uhamn1ad area at the park is clean 

According to guardian J\,1uhammad can drive a 

vechile 

Individual J\1uhain1nad does get food stamps :tv1uhammad does get food sta1nps for support \Vith 

food 

Individual J\1uhan1mad has Associate1

s Degree 11uham1nad received his Assoicates Degree 

Individual 11uhai11mad has support fro1n his dog 11uham111ad has a sn1all dog for e1notional support 

Individual lvfuhan11nad has \Vork history J\1uhan1mad guradian stated he has \Vorked before 

Individual J\1uha111n1ad utilize the transit syst.e111 J\1uhamn1ad will utlize his bus ticket 

Individual Muhammad \Vill attend his appointments J\,1uham1nad will attend his appointments. 

Individual Muh3Jnmad will n1eet with cn1 once a month J\1uhamm2d will n1eet with cm 

for f2f and every 90 dyas 

J\latural and Co1nn1unity Muhamn1ad has the support of his family 

Based Supports 

11uham1nad has the support of his sister and step 

1nother 

N·atural and Con11nunity 11uhai11mad has the support of the clinical 11uham111ad/ or guardian ,vill contact the clinical 

tean1 1 Based Supports team ..vhen needed 

Oh. 11ec t· IVCS an d I Jl t erven ions 

Need Objective Services Frequency Current Desired Con1plete J:vlet 

Measure J\1easure Date 

""""""""""""""""""""""""""""""""""""""""""""""""""""""' """' 

:tv1uhrun1nad needs to Case J'vlanage1nent: (Tl01653) Supportive Current Desired 12/12/2017 

actively participate in activities n1ay C'.1\,1 n1easure measure for 

his 1nental health include assisting, services: J\1uha1nmad Muham1nad 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 171 of 179
COP 015391

treatment to address maintaining, and face to face \Vill 1neet to continue 

the sy1nptoms of monitoring covered contact with cn1 f2f to meet \Vith 

auditory services, finding every 30 once a month cm once a 

hallucinations, necessary resources days, and every 90 1nonth for f2f 

anxiety, related to to meet basic needs, quarterly days for and every 90 

the diagnosis of coordinating care home visit, ho1ne visits. days for 

295.10 \Vith family and other and phone home visits. 

Schizophrenia agencies involved, contact 

Disorganized Type. outreach and follo\v 

up, and other 

activities as needed. 

JvJuhammad needs to I3Hl\1P Services (99211-99215, Supportive c.urrent I)esired 12/12/2017 

actively participate in Services n1ay include 90792, 90833, B!Th1P ,viii 1neasure 1neasure for 

his 111ental health ongoing 1nedication 90836, 90838, provide J\1uhmnmad J\1uham111ad 

treatJnent to address management 99354, 99355, support at will attend to continue 

the sympton1s of involving the revie\v 99358, 99359) least every his to attend his 

auditory of effects, side 90 days or appointlnent appointment 

hallucinations, effects, and more S. S. 

anxiety, related to adjustment of frequently if 

the diagnosis of medications to clinically 

295.10 prevent, stabilize, or in<licat 

Schizophrenia an1eliorate syinpton1s 

Disorganized Type. of a behavioral 

health condition. 

Muha1nn1ad needs to RJ\l- Services: as (TI002, 1'1016) RN ,viii Current Desired 12/12/2017 

actively participate in needed through provide measure 1neasure for 

his 1nental health activities that 1nay support as J\1uha1nmad J\1uhan11nad 

treatment to address include the clinically will attend to be more 

the sympto1ns of 1neasure1nent of vital indicated his RN consistent at 

auditory signs, assess1nent based on appointn1ent attending his 

hallucinations, and monitoring of psychiatric S. RN 

an-"Xiety, related to physical/medical and 1nedical appointment 

the diagnosis of status, revievv of the need. S. 

295-10 effects and side 

Schizophrenia etTects of 

Disorganized Ty'pe. medications and 

adn1inistration of 

medications. 

""""""""""" 

Muhamn1ad needs to Rehab Specialist: (H201412, RS will Current Desired 12/12/2017 

actively participate in Rehab Specialist H201453, meet 1neasure 1neasure for 

his 1nental health services may include H201499 , annuallv to Muha1nn1ad 1'Auham111ad , 

treatinent to address assessment of level H202553, assess level needs to to meet with 

the sy1nptoms of of assistance he/she H202599, of meet with RS annually 

auditory requires to create, H202712, assistance RS for or as needed_ 

hallucinations, plan, and 1!202753, required to services. 

anxiety, related to successfully work H202799) \vork 

the diagnosis of towards towards 

295.10 accomplishing treatn1ent 

Schizophrenia his/her goals. 

Disorganized Type. e1nployment/leaming 

and social 

engagement goals. 

Muhainmad needs to Peer/Family Mentor: (1-1003812, Peer/Family Current Desired 12/12/2017 

actively participate in Services 1nay H003853, l\tfentor to measure 1neasure for 

his mental health include group H003899) meet as Muhamn1ad l\1uham111ad 

treatment to address teaching independent needed to needs to to reach out 

the syinptoms of living, social, and provide n1eet with to the 

auditory com1nunications support for PS/Fl\1 PSIFtvl when 

hallucinations, skills to persons BB.Ras needed for 

anxiety, related to and/or their fa1nilies ·well as their support 

the diagnosis of in order to n1axin1ize fa111ily. services. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 172 of 179
COP 015392

295.10 the person's ability to 

Schizophrenia live and participate 

Disorganized Ty1Je. in the co1nmunity 

and function 

independently. 

Muhammad needs to TRANSPORTAT!O (AOl 10; A0120; As needed Current Desired 12/12/2018 . . 

actively participate in N CM \Vill support S2015) based on n1easure 1neasure for 

his mental health by assisting in clinical or Muhmn1nad Muhammad 

treatlnent to address coordinating, medical utilze the to continue 

the syinptoms of arranging, or need. transportatio to utilize the 

auditory providing clinically ns system. transportatio 

hallucinations, necessary n services to 

anxiety, related to transportation for attend 

the diagnosis of medically necessary appointment 

295.10 behavioral health S. 

Schizophrenia services. 

Disorganized Type. 

Living Goal: I v.rant C111 ,vill assits vvith l\1uhm11111ad will Nluharnrnad Current Desired 12/12/2017 

o,vn apartment. housing reterrals and attend ,vith \vill meet 1neasure 111easure for 

other resources for intake for ,vith c1n as J\1uharn,nad J\1uha1nn1ad 

housing. housing needed for is homeless. to attain 

referrals. housing housing. 

resources. 

Learning!W orking RS will help Muhammad will Nluharnmad Current Desired 12/1212017 

Goal: I vvant to work Nluharnrnad 1vith 111eet vvith RS for \vill 111eet measure 111easure for 

part-time to earn resources for supportive \vith RS a-; Muha111rnad J\1uhm11111ad 

1noney employ1nent. employn1ent needed for is not to attain 

e1nployen1nt currently en1ployment. 

.. employed. 

Social Goal: I vvant C1n will help with Muhammad will Muha1nmad Current Desired 12/12/2017 

attend con1munity resources for meet ,vith RS to will meet n1easure measure for 

groups com1nunity groups co1nmunity ,vith RS/ J\1uha1nmad Muham1nad 

and activities. support services Clv1 as needs to jon to find a 

needed for a community co1nmunity 

support group group he 

senvces. support. likes to 

attend. 

Health Goal: I want C1n ,vill schedule Muhamn1ad Muhan1mad Current Desired 12/12/2017 

to visit ,vith PCP PCP appointment at meet ,vith the needs to measure 111easure for 

yearly for routine the new clinic. PCP for intake. meet with J\1uhmnrnad J\1uhrnn1nad 

check-up pc:p as needs a PC~P. to attend 

needed for intake for 

health PCP 

concerns. """""""""""""""""""""""""""""""""""·""' 

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""'" 

Strengths Used Success Detennined /\chieved J\lleasure Program 

J\1uhrnnmad can cook and Success is determined by Supportive 

clean. Muham1nad has :tv1uhammad 1neeting ,vith 

support fron1 his dog. cm f2f once a month and 

t.1uham1nad will n1eet every 90 days for IfV 

with cm once a month for 

f2f and every 90 dyas, 

Muhamn1ad will attend 

his appointments 

t.1uhainrnad ha-; support Success is detennined by Supportive 

from his dog, Muhammad Jvluha1nmad attending his 

will attend his appointments. 

appointn1ents, 

Muhamn1ad has the 

support of his family, 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 173 of 179
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:tvluhmn1nad has the 

support of the clinical 

tea1n 

:tvfuham1nad has support Success is detennined by Supportive 

fro111 his dog, Muhmnrnad :tvluhan1n1ad attending his 

utilize the transit s:ystem, appointn1ent 

Muhamn1ad will attend 

his appointinents, 

Muha1nn1ad has the 

support of his family, 

l\1uha1nmad has the 

support of the clinical 

team 

Muhamn1ad car drive, Success is detern1ined by Supportive 

Muham1nad has Muha1nrna<l meeting with 

J\ssociate's Degree, RS annually 

J'vfuha1nmad has support 

fro1n his dog, Muha1nmad 

has work history, 

t.1uham1nad utilize the 

transit systen1, 

Muhammad will attend 

his appointments, 

t.1uhmn1nad has the 

support of his family, 

l\{uha1nmad has the 

support of the clinical 

team 

Muhammad has support Success is determined by Supportive 

from his dog, :ivluhfnnmad 1\lfuha1nma<l meeting ,vith 

utilize the transit system, PS/Ft.1 as needed for 

Muha1nn1ad wi 11 attend support services 

his appointinents, 

h1uha1nmad will meet 

with c1n once a n1onth for 

f2f and every 90 dyas, 

l\{uhan1mad has the 

support of his family, 

Muhamn1ad has the 

support of the clinical 

tea111 

t.1uhmnmad has support Success is detennined by Supportive 

from his dog, Muhammad !Yluha1nmad utlizing the 

utilize the transit system, transportation services 

Muhammad will attend when needed 

his appointments, 

t.1uhmn1nad will meet 

·with cn1 once a month for 

f2f and every 90 dyas, 

t.1uhainmad ha-; the 

support of his fan1ily, 

l\1uham1nad has the 

support of the clinical 

team 

Muha1nn1ad can cook and Success i9s detennined Supportive 

clean, lvluhammad does by Muhammad attain 

get food stamps, housing. 

t.1uhainmad ha-; support 

from his dog, Muhamn1ad 

will attend his 

appointments, 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 174 of 179
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:tv1uhrun1nad will meet 

with cn1 once a month for 

f2f and every 90 dyas, 

Muhan11nad has the 

support of the clinical 

team 

Muhamn1ad has Success is dtennined by Supportive 

i\ssociate's Degree, Iviuha1nmad \.Vorking part 

Muha1nn1ad has work time 

history, 11uham1nad 

utilize the transit svstem, J ' 

lvfuhammad will attend 

his appointments, 

11uhmnrnad has the 

support of his family, 

Muhamn1ad has the 

support of the clinical 

tea1n 

Jv[uhan1mad can cook and Success is dctennined by Supportive 

clean, Muhamn1ad utilize Jviuha1nmad attending 

the transit system, groups out in the 

Muhammad will meet community. 

with cn1 once a month for 

f2f and every 90 dyas, 

Muha1nn1ad has the 

support of his family, 

11uha1nmad has the 

support of the clinical 

team 

Muhamn1ad can cook and Success is detem1ibed by Supportive 

clean, Muhan1rnad car Muha1nrnad meeting with 

drive, lvluhammad has PCP 

support ii-om his dog, 

11uha1nmad will attend 

his appointn1ents, 

lvf.uham1nad has the 

support of his family, 

Muhammad has the 

support of the clinical 

..,..,. team ______ . 

1\dditio11al Services 

Discl1arge Plan 

Muhanunad has a guardian his sister Mussaltina Muhaymin who can be reached at 786 I\,fussallina is also 

Muhannnad payee when l\lI uhanm1ad receives his benefits. 1\.1uhannnad \Vas assessed for special assistance, and it was 

dete1mined that he did need it and the fonn was filled out ,vith his sister and is waiting on penneant guardianship. l'heretore, 

temporary f om1 ,vas filled out. Muhan1ITiad is unable to understand tl1e G&A process. 11uhamn1ad fully pa1ticipated in his 

treattnent plan a.long with his guardian l\!Iussallina, and reported that did ,vant his sister (l\llussallina) ai1d step 1nother (Annie 

Ruth Davis) involved in his treatment plam1ing and appointn1ents. Mussallina 1v1uhayn1in is 1v1uhamn1ad ten1porary 

guardianship until she is able to get pe1meant guardianship, l\llussallina can be reached at 786 

Ix Yes, client has received a copy ofthis plan. 

(i Yes, client agrees with the types and levels of services in the ISP. 

(~ No, client disagrees with the types ru1d/or levels of some or all of the services included in the plru1. By checking 

this box~ client \Vill receive the services agreed to receive and may appeal the treatn1ent tean1's decision to not include all 

types and/or levels of service that have been requested. 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 175 of 179
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I Client has received a Notice of i\ction (PlVI Fonn 5.1. l if disagreetnent concerns a Title XLX/XXI covered service) 

1 Client has received the Notice of Decision & Right to i\ppeal for Individual with a Serious l\1ental Illness (l'l\1 Form 

5.5.1 if disagreement pertains to a Non-Title XLX/X,XJ covered service). 

Service Plan Rights Acknow1edgement for Persons who are Title XIXIA,---XI and/or SMI: 

My service plan has been reviewed ,vith me by my behavioral health provider. l kno,v what services I ·will be getting and ho,v often. All changes in the services 

have been explained to me. I have n1arked my agreement and/or disagreement ,v:ith each service. I know that :in most cases, any reductions, tenninations, or 

suspensions (s1'opping for a se1 tin1e fraine) of cunent sen~ces will begin no earlier than 10 days fron1 the date of the plan. I ktlO\V tha1 I cm1 ask for this to be 

sooner. 

ff I do not agree 1vith so1ne or all of the sen,ices tliat have been authorized :in this plan, I have noted that on 1ny plan. I know if the service asked for was denied, 

reduced, suspended or knninated, that 1ny behavioral health provider ,vill give rne a letter that tells n1e why the de(ision \Vas niade. TI1at letter \Vill tell 111e how 

to appeal the decision that has been n1ade about 1ny services. The letter \Vlll also tell n1e how I can request continued services. 

My behavioral health provider has told n1e how the appeal process works. I knt'<\V ho\v I can appeal service changes I do Tit'<l agree with. I knovv that I can 

cliange my 111ind later abou1· services I agree with today. I know 1hat if I change 1ny rnind before the changes go into effect, I \V:ill get a leHer that 1'ells n1e 1'he 

reason my se1vices changed. 'The letter will also tell me about my appeal rights. 

I kno\v that if I need rnore services or other services lhan what I an1 getting, I can call n1y behavioral health provider at (602)278-1414 - to talk about this, My 

behavioral heallh provider ,vill call rne back v1rithin 3 working clays. Once I have talked with 1ny behavioral heallh provider, s/he ,vill give rne a decision about 

that request Virithin 14 days. lf the behavioral health provider is not able to make a decision about my request within 14 days, s/he will send me a letter to let me 

k:r10\v 1nore time is needed to make a decision. 

Review Date (Objective Target Date): 12/12/2017 

Sign=:! By: :.Iusstllin3.).luhs.ymin 

Person/Guardian 

Electronicallv signed by: Kimberly Bryant BHT /s/ 

Signature 

Participant Signature 

/SIGNATURE PAD} 

Participant Signature 

{SJGN1\TlJRE Pi\D} 

Participant Signature 

Participant Signature 

/SIGNATURE PAD} 

Participant Signature 

{SIGN,~TURE PAD} 

Participant Signature 

12/12/2016 ---- ,------------~-----

Date 

12/12/2016 

!)ate 

12/12/2016 

"~""""-·-·-""" 

Date 

12/12/2016 

Date 

12/12/2016 

Date 

Date 

12/12/2016 

Date 

!2/12/2016 

Date 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 176 of 179
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*}'or Behavioral Health Professional Signatures see BHServicePlanAttestatiou 

CIS ID: --3099 

AHC'.CCS ID: -0335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 177 of 179
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BH Service Plan Affidavit 

Per A.A.C. R9-10-101l(B)(3) Assessment and Treatment Plan 

If a behavioral health assessment is conducted by 

a. Behavioral health tecl111ician or a registered nurse~ within 72 hours a behavioral health professional certified or licensed 

to provide the behavioral healtl1 services needed by the patient reviews and signs the behavioral health assessment to ensure 

that the behavioral healtl1 assessment identifies the behavioral health services needed by the patient; 

or 

b. Behavioral health paraprofessional, a behavioral health professional certified or licensed to provide the behavioral health 

services needed by the patient supervises the behavioral health paraprofessional during the completion of the behavioral 

health assessment and signs the behavioral healtl1 assessment to ensure tl1at the assess1nent identifies the behavioral health 

services needed by the patient. 

I attest that I have revie\ved and approved the assessn1ent or treatn1ent plan co1npleted by the BlIT based on the above 

standard. 

Electronically Signed by: Julia Jvfatthies BHP /s/ 

Signature of.Behavioral.Health Professional 

Julia Matthies BHP 

Natne of Behavioral Health Pro_fessional 

Assessment Date: 12/12/2016 

Date of Re,rielv: 12/22/2016 

CIS ID: 1101103099 

AHCCCS ID: -0335 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 178 of 179
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ADHS FORM MH-211 

Notice of Legal Rights for Persons ,vith Serious Me11tal Illness 

If you have a serious or chronic mental illness, you have legal rights under federal and state law. Some of these rights include: 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

• 

The right to appropriate mental health services based on your individual needs; 

'J'he right to participate in all phases of your mental health treattnent. including individual service plan (ISP) meetings; 

The right to a discharge plan upon discharge from a hospital; 

The right to consent to or refuse treattnent ( except in an emergency or by court order); 

1'he right to treatment in the least restrictive setting; 

''fhe right to ffcedom ±forn unnecessary seclusion or restraint~ 

The right not to be physically, sexually, or verbally abused; 

The right to privacy (mail, visits, telephone conversations); 

The right to file an appeal or grievance \Vhen you disagree ,vit11 the se1vices you receive or yow· rights are violated; 

The right to choose a designated rcprcsentative(s) to assist you in ISP meetings and in filing grievances; 

'fhe right to a case 1nanager to work vvith you in obtaining the services you need; 

The right to a \Vritten ISP that sets forth the services you \vill receive; 

The rioht to associate with others· 

b ' 

1'he right to confidentiality of your psychiatric records; 

'Ihe right to obtain copies of your own psychiatric records (unless it would not be in your best interest to have them); 

The right to appeal a court-ordered involuntary co1nmitment and to consult \Vith an attorney and to request judicial review of 

court-ordered commitment every 60 days; 

'!'he right not to be discriminated against in employment or housing . 

If you would like information about your rights, you may request a copy of the "Your Rights in i\rizona as an Individual with 

Serious l\1ental Illness" brochure or you may also call the Arizona Department of Health Services, Office of Human Rights at 

1-800-421-2124 or at (602) 364-4574. 

ADHS/DBHS Fonn l\lH-211 (9/93) 

Case 2:17-cv-04565-DLR Document 382-8 Filed 11/30/21 Page 179 of 179