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Arlington Regional Medical Center
Emergency Department · Confidential Patient Record
Morales, Daniel A. DOB: 03/14/1999  |  MRN: 2025-04471  |  ED Arrival: 09/06/2025 · 11:12 AM
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Daniel A. Morales

Age 26  ·  He/Him  ·  Criminal Justice, Junior  ·  Army Veteran, OEF  ·  Came in at sister’s urging · Triage flagged SI
⚠ PHQ-9 Item 9 Flagged PCL-5 Elevated AUDIT-C Positive VA-Documented PTSD Trainee Case, Supervised
Abbreviations used in this chart
PHQ-9
Patient Health Questionnaire, 9-item depression screen
GAD-7
Generalized Anxiety Disorder, 7-item screen
PCL-5
PTSD Checklist for DSM-5
AUDIT-C
Alcohol Use Disorders Identification Test, consumption items
DAST-10
Drug Abuse Screening Test, 10-item
PTSD
Posttraumatic Stress Disorder
TBI
Traumatic Brain Injury
OEF
Operation Enduring Freedom (Afghanistan)
VA
U.S. Department of Veterans Affairs
MRN
Medical Record Number
ROI
Release of Information
NKDA
No Known Drug Allergies
QHS
Taken at bedtime (medication timing)
Arlington Regional Medical Center
Emergency Department · Behavioral Health
Emergency Department Triage Note
Documented at triage · Prior to behavioral health consult
Form ARMC-100  |  Rev. 06/2025
A. Arrival Details
Date of Arrival
09/06/2025
Time
11:12 AM
Mode of Arrival
Walk-in (drove himself)
Accompanied By
None (sister reached by phone)
Triage Nurse
R. Okafor, RN
Acuity
ESI 2 · Behavioral health
Vitals (11:19 AM)
BP 132/84 · HR 88 · RR 16
Temp / SpO2
98.2°F · 99% RA
Orientation
Alert and oriented x4
B. Chief Concern (Patient's Words)
"Rough couple of nights. My sister wanted me to come get checked out."
Asked directly at triage about thoughts of suicide: "I'm here, aren't I?" Declined to elaborate at the desk; deferred to the screening forms.
Nurse note (collateral): Patient's sister (Mariana M.) phoned the ED desk shortly after his arrival, with his knowledge. States patient called her around 2 AM the night prior and told her "how bad it got"; she asked him to promise to come in this morning. States he has seemed withdrawn and has not been answering texts for several days. Patient confirmed the call took place; declined to add detail at triage.
C. Demographics & Status (Self-Reported at Triage)
Age
26
Veteran Status
U.S. Army (one tour, Afghanistan, 2019-2020); separated 2020
Living Situation
Off-campus, alone (Arlington)
D. Affect & Engagement at Triage
Patient was quiet, polite, brief. Spoke clearly. Flat affect; visibly tired. Long pauses before responses to open-ended questions. Used minimizing language ("I'm fine," "it's not a big deal") when invited to elaborate. Asked twice how long this would take and whether he "can still leave." Cooperative with triage logistics and with the screening forms.
E. Triage Safety Screening
Columbia Protocol (C-SSRS) Screener administered at triage per hospital policy: POSITIVE. Recent suicidal ideation endorsed; denies intent or plan; declined to elaborate at the desk. Full behavioral health screening battery provided for completion in bay (see Standardized Screening Battery; PHQ-9 19 with item 9 endorsed, PCL-5 55). Asked directly about current intent: patient denies intent or plan ("I'm not gonna do anything"). Recent crisis episode indicated by sister's collateral and the positive screen.
Patient agreed to wait for behavioral health consult. Placed in ED Bay 14 (ligature-resistant); belongings secured per protocol; no weapons on person. Continuous video monitoring per protocol pending behavioral health evaluation.
F. ED Provider Medical Screening
Medical screening examination performed by A. Chen, MD, 11:52 AM. Alert and oriented x4, cooperative. No acute medical complaints. Denies ingestion or overdose. No evidence of acute intoxication; clinically sober; point-of-care breath alcohol 0.000 (11:58 AM). Physical examination unremarkable; no acute findings. Per history, examination, and normal vital signs, laboratory testing is not indicated (ACEP clinical policy). Patient is medically appropriate for behavioral health evaluation and disposition planning in the ED.
G. Behavioral Health Consult Order
Ordered By
A. Chen, MD (ED attending)
Order Placed
09/06/2025 · 11:31 AM
Consult reason: "Triage suicide screen (C-SSRS Screener) positive in a veteran patient presenting after a reported crisis episode; PHQ-9 item 9 endorsed on the ED screening battery. Behavioral health evaluation and disposition planning requested; crisis response planning as indicated."
Prior treatment (per patient): Patient endorsed prior VA counseling for PTSD, self-reported having stopped attending approximately 8 months ago. Did not elaborate on reason for stopping. Follow up in consult.
H. Forms Completed in the ED
  • Consent for behavioral health evaluation, signed at registration ✓
  • Release of Information (VA records), offered and signed ✓ (records requested)
  • Behavioral health questionnaire (BPS-S), completed in bay while waiting ✓
  • Screening battery (PHQ-9, GAD-7, PCL-5, AUDIT-C, CAGE, DAST-10), completed ✓
I. Consult Assignment
Date
09/06/2025
Time
1:40 PM
Location
ED Bay 14
Provider
Behavioral health trainee (supervised by L. Kim, LCSW)
Type
ED behavioral health evaluation · Crisis response planning as indicated
J. Notes for Behavioral Health Clinician
  • Veteran-status patient. Trauma-informed pacing recommended; honor military identity in language and approach. Avoid clinical jargon; this patient is unlikely to identify with therapy framing.
  • Did not self-initiate. Came at his sister's urging after a reported crisis episode. Allow time for rapport before structured assessment. Validate reluctance rather than pushing through it.
  • Worried about admission. Asked twice whether he "can still leave." Expect guardedness driven by fear of a psychiatric hold; address honestly and early.
  • Minimizing pattern. "I'm fine" used reflexively at triage. Avoid forcing disclosure; build trust first.
  • Do not push on deployment specifics unless the patient opens that door himself.
  • VA-documented PTSD, reportedly stopped VA counseling ~8 months ago. Complete formal suicide risk assessment (C-SSRS framework) in consult; firearm access unknown at triage and must be assessed for means safety.
Triage Nurse Signature
Rosa Okafor, RN
Date / Time
09/06/2025 · 11:38 AM
Arlington Regional Medical Center
Emergency Department · Behavioral Health
Consent for Behavioral Health Evaluation & Services
Read carefully before signing
Form ARMC-100  |  Rev. 08/2025
Patient Information
Last Name
Morales
First Name
Daniel
Middle Initial
A.
Date of Birth
03/14/1999
MRN
2025-04471
Phone
210-555-0147
Email
damorales@university.edu
Nature of Services
The Emergency Department at Arlington Regional Medical Center provides behavioral health evaluation and brief intervention services. Services are provided by licensed mental health professionals and by supervised graduate trainees completing their clinical training. Your clinician today is a graduate-level behavioral health trainee under the direct supervision of a licensed clinical supervisor. You have the right to know the training level of your provider and to ask questions at any time.
The evaluation is a conversation, and you may ask questions or take breaks at any time. Decisions about next steps, including any plan you build with your clinician and any follow-up care, are made collaboratively wherever clinically possible.
Confidentiality & Its Limits
Everything you share in this evaluation is confidential and will not be released without your written consent, except in the following circumstances required or permitted by law:
DM
Risk of serious harm to self or others: If you present a serious and imminent risk of harm to yourself or another identifiable person, your clinician is required to take steps to protect safety, which may include contacting emergency services or third parties.
DM
Abuse or neglect of a child, elder, or dependent adult: Your clinician is a mandated reporter and is required by law to report suspected abuse or neglect to the appropriate authorities.
DM
Court order: Records may be released pursuant to a valid court order or subpoena.
DM
Supervision: Your trainee clinician discusses cases with their clinical supervisor for training and quality assurance purposes. All supervisory staff are bound by the same confidentiality standards.
DM
Veteran-specific note: Information shared during behavioral health services at this hospital is not automatically shared with the VA, Department of Defense, or any military branch. A separate Release of Information is required for any such disclosure.
Electronic Records & HIPAA
Your records are maintained in a secure electronic health record system. You have the right to access your records, request corrections, and receive an accounting of disclosures as provided under HIPAA. A full Notice of Privacy Practices is available at the front desk and on our website.
Emergency Procedures
If you experience a mental health emergency after leaving the hospital, contact the 9-8-8 Suicide and Crisis Lifeline (call or text 9-8-8), the Veterans Crisis Line (9-8-8, then press 1), or return to the nearest emergency department.
Questions Before We Begin
Do you have any questions or concerns about these policies?
(left blank)
Acknowledgment & Signature
By signing below, I acknowledge that I have read and understood this Informed Consent form, that my questions have been answered, and that I agree to participate in behavioral health evaluation and services under the terms described above.
Patient Signature
Daniel A. Morales
Signed at ED registration
Date
09/06/2025
Trainee Clinician (Witness)
Date
Witnessing the consent is part of your role on this case. Sign it before you meet Daniel.
Arlington Regional Medical Center
Emergency Department · Behavioral Health
Authorization for Release of Information
HIPAA-Compliant Disclosure Authorization
Form ARMC-200  |  Rev. 08/2025
⚠ Clinical Flag, Review Before SessionPatient did not complete the receiving provider name or address. The VA provider field was left blank. Follow up conversationally to identify Daniel's current VA care team and whether he wishes to maintain the release.
Patient Authorizing Release
Name
Daniel A. Morales
Date of Birth
03/14/1999
MRN
2025-04471
Disclosing Party (Sending Records FROM)
This Organization
Organization
Arlington Regional Medical Center, Emergency Department
Address
815 W. Randol Mill Rd, Arlington, TX
Receiving Party (Sending Records TO)
External Provider
Provider / Organization Name
(not completed)
Provider Type
VA Primary Care / Mental Health
Address
(not completed)
Phone / Fax
(not completed)
Information to Be Released
✓
Mental health treatment records and progress notes
✓
Psychiatric / medication management records
✓
Psychosocial assessment documentation
✓
Diagnosis and treatment summary
Substance use treatment records (requires separate authorization under 42 CFR Part 2)
HIV/AIDS-related information (requires separate state-specific authorization)
Purpose of Release
✓
Coordination of care between providers
Referral to outside services
At patient's request
Duration & Right to Revoke
This authorization expires one year from the date of signature unless revoked earlier in writing. You may revoke this authorization at any time by submitting a written request to the hospital's Health Information Management department. Revocation does not apply to information already released in good faith prior to the revocation.
You understand that authorizing this release is voluntary and that refusing to sign will not affect your eligibility for services at this hospital.
Patient Signature
Daniel A. Morales
Date
09/06/2025
Records Status (Office Use)
ROI signed 09/06/2025. Records requested from South Texas Veterans Health Care System same day; request logged in chart. Records NOT YET RECEIVED at time of consult. Consult proceeds on patient self-report and ED screeners; verify VA history, TBI screening, and medication record when records arrive.
Arlington Regional Medical Center
Emergency Department · Behavioral Health
Behavioral Health Questionnaire (BPS-S)
Completed by patient in the ED while awaiting consult
Form ARMC-300  |  Rev. 08/2025
A. Identifying Information
Last Name
Morales
First Name
Daniel
Preferred Name
Daniel
Pronouns
He/him
Date of Birth
03/14/1999
Age
26
Race / Ethnicity
Hispanic / Latino
Primary Language
English
Phone
210-555-0147
Email
damorales@university.edu
Emergency Contact
Roberto Morales (father) · 210-555-0182
Academic Year
Junior
Major
Criminal Justice
Current GPA
2.1 (was 3.4)
Living Situation
Off-campus, alone
Employment
Part-time, Home Depot
Relationship Status
Single
Veteran Status
Yes, U.S. Army, OEF
Current VA Enrollment
Yes
B. Presenting Concern
What brings you in today?
rough week. my sister made me promise
How long has this been a concern?
(blank)
Sought help before?
Yes, VA, stopped
What would you like help with today?
(left blank)
C. Mental Health History
Prior Diagnoses
PTSD (VA-documented)
Prior Treatment
VA individual counseling, stopped 8 mo ago
Prior Psychiatric Hospitalization
None
Prior Suicide Attempts
(not answered, blank)
Family Mental Health History
(blank)
Current Medications
some stuff from the VA
Allergies
NKDA
VA Provider Name
(not listed)
D. Medical & Physical Health
Primary Care Provider
VA, no name listed
Last Physical Exam
don't remember
Chronic Conditions
None reported
Recent Hospitalizations
None
Head Injury / TBI
possible
TBI Details
(blank)
Sleep
problems, "yeah"
Appetite
changes noted
Energy Level
low
E. Military History
Branch
Army
Years of Service
2017 - 2020
Rank at Discharge
Specialist (E-4)
MOS
11B Infantry
Deployments
1, Afghanistan 2019–2020
Combat Exposure
prefer not to say
Discharge Status
Honorable
Service-Connected Disability
Yes
Concerns about military info affecting care
Yes, "I don't want it to follow me"
F. Social & Family History
Grew Up In
San Antonio, TX
Parents
Both living, married
Siblings
1 younger sister
Relationship with Family
complicated since I got back
Current Support Network
not really
Financial Stress
Yes, GI Bill + part-time
Legal History
None
Spiritual / Religious
(blank)
G. Academic Concerns
Current GPA
2.1
Prior GPA (last year)
3.4
Classes Missed This Semester
a few
Describe any academic difficulties:
can't concentrate. don't really care right now
Arlington Regional Medical Center
Emergency Department · Behavioral Health
Standardized Screening Battery
Completed by patient in the ED while awaiting consult
Form ARMC-400  |  Rev. 08/2025
PHQ-9
Patient Health Questionnaire, Depression Screen
Score: 19, Moderately Severe
Over the last two weeks, how often have you been bothered by any of the following? (0=Not at all · 1=Several days · 2=More than half the days · 3=Nearly every day)
1. Little interest or pleasure in doing things
3, Nearly every day
2. Feeling down, depressed, or hopeless
3, Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
3, Nearly every day
4. Feeling tired or having little energy
3, Nearly every day
5. Poor appetite or overeating
1, Several days
6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down
2, More than half the days
7. Trouble concentrating on things, such as reading the newspaper or watching television
3, Nearly every day
8. Moving or speaking so slowly that others have noticed, or being so fidgety or restless that you have been moving around a lot more than usual
0, Not at all
9. Thoughts that you would be better off dead, or of hurting yourself in some way ⚠
1, Several days
Total: 19  ·  Moderately Severe Depression · Item 9 positive · Requires direct clinical assessment this consult
GAD-7
Generalized Anxiety Disorder Scale
Score: 11, Moderate Anxiety
Over the last two weeks, how often have you been bothered by? (0=Not at all · 1=Several days · 2=More than half the days · 3=Nearly every day)
1. Feeling nervous, anxious, or on edge
2, More than half the days
2. Not being able to stop or control worrying
1, Several days
3. Worrying too much about different things
1, Several days
4. Trouble relaxing
3, Nearly every day
5. Being so restless that it is hard to sit still
1, Several days
6. Becoming easily annoyed or irritable
2, More than half the days
7. Feeling afraid as if something awful might happen
1, Several days
Total: 11  ·  Moderate Anxiety · Threshold ≥10 warrants further evaluation
PCL-5
PTSD Checklist for DSM-5, Veteran/Military Version
Score: 55, Well Above Threshold (≥33)
In the past month, how much have you been bothered by? (0=Not at all · 1=A little bit · 2=Moderately · 3=Quite a bit · 4=Extremely)
Intrusion Symptoms (Criterion B)
1. Repeated, disturbing, and unwanted memories of the stressful experience
3, Quite a bit
2. Repeated, disturbing dreams of the stressful experience
4, Extremely
3. Suddenly feeling or acting as if the experience were actually happening again (flashbacks)
2, Moderately
4. Feeling very upset when something reminded you of the experience
3, Quite a bit
5. Having strong physical reactions when reminded (heart pounding, trouble breathing, sweating)
2, Moderately
Avoidance (Criterion C)
6. Avoiding memories, thoughts, or feelings related to the experience
3, Quite a bit
7. Avoiding external reminders of the experience (people, places, activities, objects, situations)
3, Quite a bit
Negative Alterations in Cognition & Mood (Criterion D)
8. Trouble remembering important parts of the stressful experience
2, Moderately
9. Strong negative beliefs about yourself, other people, or the world
2, Moderately
10. Blaming yourself or someone else for the experience or what happened
1, A little bit
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame
3, Quite a bit
12. Loss of interest in activities that you used to enjoy
3, Quite a bit
13. Feeling distant or cut off from other people
4, Extremely
14. Trouble experiencing positive feelings (happiness, love, joy)
3, Quite a bit
Hyperarousal & Reactivity (Criterion E)
15. Irritable behavior, angry outbursts, or acting aggressively
2, Moderately
16. Taking too many risks or doing things that could cause you harm
0, Not at all
17. Being "super-alert," watchful, or on guard
4, Extremely
18. Feeling jumpy or easily startled
3, Quite a bit
19. Having difficulty concentrating
3, Quite a bit
20. Trouble falling or staying asleep
4, Extremely
Total: 55  ·  Well above clinical threshold of 33 · Consistent with VA-documented PTSD diagnosis
AUDIT-C
Alcohol Use Disorders Identification Test, Consumption
Score: 5, Positive Screen (Men ≥4)
1. How often do you have a drink containing alcohol?
3–4 times a week (3 pts)
2. How many standard drinks containing alcohol do you have on a typical day when drinking?
2–3 drinks (1 pt)
3. How often do you have 6 or more drinks on one occasion?
Never (0 pts)
Total: 5  ·  Positive screen for hazardous drinking in men (threshold ≥4) · Warrants follow-up functional assessment
CAGE
Cut-Annoyed-Guilty-Eye Opener Alcohol Screening
Score: 1, Below Threshold
C, Have you ever felt you should Cut down on your drinking?
Maybe (1 pt)
A, Have people Annoyed you by criticizing your drinking?
No (0 pts)
G, Have you ever felt bad or Guilty about your drinking?
No (0 pts)
E, Have you ever had a drink first thing in the morning (Eye opener)?
No (0 pts)
Total: 1  ·  Below threshold of ≥2 · AUDIT-C positive, follow up on frequency and function of alcohol use
DAST-10
Drug Abuse Screening Test
Score: 1, Low Level
The following questions concern information about your possible involvement with drugs, not including alcohol or tobacco, during the past 12 months.
1. Have you used drugs other than those required for medical reasons?
Yes, in the past, not now
2. Do you abuse more than one drug at a time?
No
3. Are you always able to stop using drugs when you want to?
Yes
4. Have you had blackouts or flashbacks as a result of drug use?
No
5. Do you ever feel bad or guilty about your drug use?
No
6. Does your spouse or parents ever complain about your involvement with drugs?
No
7. Have you neglected your family because of your use of drugs?
No
8. Have you engaged in illegal activities in order to obtain drugs?
No
9. Have you ever experienced withdrawal symptoms when you stopped taking drugs?
No
10. Have you had medical problems as a result of your drug use?
No
Total: 1  ·  Low level · Prior use acknowledged · No current concern indicated by screen alone
Arlington Regional Medical Center
Emergency Department · Behavioral Health
Pre-Session Clinical Summary
Trainee use only, review before the consult begins
Form ARMC-500  |  Auto-generated 09/06/2025
🔴 Priority Flags, Require Direct Assessment This ConsultRecent crisis episode (sister collateral, ~2 AM call) · PHQ-9 Item 9 endorsed (several days) · Prior suicide attempt history unanswered · Firearm access unknown, must be assessed for means safety · Veteran population, elevated risk base rate
🟡 Clinical Flags, Address When Clinically AppropriateAUDIT-C positive (score 5) · Sleep severely impaired · Social isolation endorsed (PCL-5 item 13: Extremely) · VA provider not identified · TBI possible, unexplored · Medication list incomplete
Screening Score Summary
19
PHQ-9
Mod. Severe
11
GAD-7
Moderate
55
PCL-5
Above threshold
5
AUDIT-C
Positive ≥4
1
DAST-10
Low level
Provisional Diagnoses (DSM-5-TR)
ICD-10 / DSM Code
Diagnosis
Status
309.81 / F43.10
Posttraumatic Stress Disorder, Chronic
VA-Documented
296.xx / F32.x
Major Depressive Disorder, Rule Out
Pending Assessment
305.00 / F10.10
Alcohol Use Disorder, Mild, Rule Out
Pending Assessment
Medications (Incomplete, Verify in Session)
Medication
Dose
Indication
Source
Prazosin
2mg QHS
PTSD nightmares
VA, presumed active
Sertraline
Unknown
Depression / PTSD
Reportedly discontinued
Session Priority Task List
What the trainee must accomplish in this consult
Assess suicide risk directly, PHQ-9 item 9 positive and a recent crisis episode by collateral. Use the C-SSRS framework with military-appropriate language, woven into the conversation, not read as a checklist. If the picture matches the triage impression (post-crisis, current ideation, no imminent intent), deliver crisis response planning before disposition. If imminent risk emerges instead, escalate per protocol.
Ask about firearm access, veteran population, service weapon likely, unknown at triage. Must be asked directly and calmly, and addressed collaboratively for means safety before discharge. Do not assume. Do not skip.
Follow up on sleep, PCL-5 item 20 Extremely, PHQ-9 item 3 Nearly every day. He will mention sleep early. Follow up specifically when he does.
Clarify medications, patient wrote "some stuff from the VA." Ask about Prazosin and prior Sertraline specifically.
Explore alcohol use, AUDIT-C positive. Contextualize, is he using alcohol to manage PTSD symptoms? Non-judgmental, functional inquiry.
Note the family connection on the emergency contact, he listed his father (Roberto). Useful as a natural opening to ask about who is in his life and current support, but be aware family relationships are complex (he left San Antonio after "too much pressure").
Address the admission fear and the confidentiality concern, he asked twice whether he can leave, and wrote "I don't want it to follow me." Explain plainly when hospitalization would and would not be warranted, that the decision is made together, and what is and is not documented. Do this early; it is what will open the session.
Brief TBI screen, marked "possible," no detail. Ask one or two follow-up questions if clinically appropriate.
Supervisor Pre-Session Guidance
🎓 Clinical Supervisor Note Daniel came through a crisis and made it to this bay, which took more than he will let on. Expect guardedness with a specific engine underneath it: he is afraid that honesty gets him admitted. Your first task is to make honesty safe, which means answering the lock-me-up question plainly when it comes, and it will come. Then invite the story of the night that brought him here; the story is the assessment. The forms give you context, not the whole story. Treat the blanks as clinical data, they tell you where he could not go yet. His answer to "what brings you in" is "my sister made me promise." That sentence is the door: somebody he loves knows how bad it got, and he let her send him here. Start there. Your job in this consult is to help him leave with a plan that is actually his.