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1989 hospitalization, social work records after the suicide attempt by my late daughter, Christina Jean Pratt

1989 hospitalization, social work records after the suicide attempt by my late daughter, Christina Jean Pratt

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Published by Gordon T. Pratt
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Published by: Gordon T. Pratt on Jun 17, 2014
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11/06/2014

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CONSENT FOR Ri FORMATION
Forest Hospital
 An Affiliate of Forest Health Systems, inc
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 Authorize --'A&^ ^°^V»^A"
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(Name of Facility)
to release the following information from my medical, psychiatric and substance abuse (if applicable) records: J Discharge Summary 3f. Psychological/Neuropsychological Testing ~] Psychiatric Evaluation Consultations
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Q Medical History & Physical X-Rays 3* Educational Reports 3 Social Assessment Or Lab Reports Q 'Other (Specify)
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Vision Screening EEG/EKG
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Forthe purpose of: Information released is not to be further disclosed or used for any purpose other than that stated in this authorization. It is understood that I have the right to revoke this consent in writing at any time. Any revocation shall be in writing, signed by me and the signature witnessed by a person who can attest to my identity. No written revocation of consent shall be effective until it is received by the person otherwise authorized to disclose records and shall have no effect on disclosures made prior thereto. I understand I have the right to inspect and copy the information released. I further understand that my refusal to consent to the release of the information specified above will prevent disclosure of such information to the facility or person named herein for the stated purpose. This authorization is valid until .
(Calendar Date) (Patient's Signature) (Parent's or Guardian's Signature) (Relationship)
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Date Date
(Witness' Signature)
Date Signatures Required: Adult patient (18 or over) and witness: Parent (or guardian) and child plus witness, if child is 12 through 17; Parent (or guardian) and witness, if child is under 12 or patient is adjudicated incompetent. 11/87 Rev.: 2/91 MCO40
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 Vilson Lane,
 Des Plaines, Illinois 60016 [*]
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FACE SHEIT
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28290
 Admit Date
04-28-89
rime
10:30 PM
Financial Acct. #
3Q0S0622
Family
 Name
SPIZZIRRI
First
CHRISTINA
Middle Home Phone
362-9497
 Address
17479 DARTMOOR
City
 Age-Yrs
14
Birth Date Month Day
 Year
08-06-74 GRAYSLAKE, IL 600
Birthplace
WISCONSIN
Race City
 _2_
How many years in: County State Occupation
STUDENT
Highest School Grade
 Completed
no I 9TH GRADE
Employer Address/School
WARREN HIGH SCHOOL. GURNEE, IL
Name Spouse/Custodial Parent
CAROL SPIZZIRRI 17479 DARTMOOR, GRAYSLAKE, IL 60030
Occupation
HOMEMAKER
Employer Address Non-Custodial Parent Employer Address
-
Notify in Case of  Emergency
CAROLGDAVID SPIZZIRRI
Relationship
PARENTS 17479 DARTMOOR. GRAYSLAKE
Guarantor Name
DAVID T. SPIZZIRRI
Address
17479 DARTMOOR
City
GRAYSLAKE
Zip
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Guarantor Employer
BAXTER
Relationship
FATHER
SS
 i
 of Patient Phone
362-9497
Phone - Employer Phone - Employer
362-9497
Social Security No.
395-80-8497
Telephone No.
362-9497
Occupation
SETUP OPR
EID
1919 S. BUTTERFIELD RD
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Years Employed
3 1/2 YRS
Phone - Employer
362-9000/2121
City
Zip
MUNDELEIN, IL
Provisional (Admitting)
 Diagnosis
MAJOR DEPRESSION DAVID SPIZZIRRI 395-80-8497 B04 - BAXTER^" 4900 BAXTER MUNDELEIN, II
Personal Physician Referral Source
DR.
 S.PETERS
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Previous Psychiatnc Admissions • Dates Evai Physician
DR. DIANELLA
Physician
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IZ0N36-0S606
Dates of Last Forest Admissicn  Attending Physician
DR. DALE GIOLAS 136-06246
Physician
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 PM
 ADMITTING PSYCHIATRIC DIAGNOSJS (DSM-111) (to be completed, within 24 hours of admission)  Admitting Physical Diagnosis: =INAL DIAGNOSIS:  Axis I: ; rincipal:
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TCtO<?/Z) STRUCT
Major Depression, Single, non psychotic
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Secondary:  Axis II: M.D.
 
Forest Hospital
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Ralph C MenuziM, M
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Mcdtcai Director Chris E. Stout,
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 11 Chief Psychologist
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" TN^^iKk/KA'iiTON REPLY Date:
Re:
 Dl __
D The information requested is enclosed. The material contained herein is confidential and is being provided in response to a written authorization, subpoena, or statute. Further disclosure by the receiving party for any  puipose other than that stated in the request is prohibited. ^ The fee for this sen/see is'—. Checks are payable to Forest Hospital. Send to the attention of the Medical Record Department. The copies you have requested are incomplete. They will be forwarded to you upon completion of the medical record. The patient is now in the hospital and his medical record is not available for correspondence purposes at this time. We will complete your request when he/she is discharged. The patient's authorization to release his medical records is lacking. Please have the patient sign an authorization for disclosure of confidential information. Have the parent (or legal guardian) and patient sign consent for a minor patient between the ages of 12 and 18. In order to process this request, we will need proof of legal guardianship. Due to hospital policy, we require the original consent form. Upon receipt of the original consent, we will be  pleased to forward the requested information. In order to properly identify the above-named patient, we are in need of some additional information. Please send the patient's attending physician's name., the exact dates of admission and discharge, date of birth, and/or change of name. After checking our files thoroughly, we regret to inform you that we can find no record on the above-named  patient. Due to the Illinois Mental Health & Developmental Disabilities Confidentiality Act, which requires a number of specific items, we are enclosing an authorization which complies with this requirement. Upon receipt of the completed authorization, signed by the appropriate person(s) and witnessed, we will be pleased to forward the requested information.
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