| Sample, Pat Q |
| 47 Y old Female, DOB: 05/11/1979 |
| Account Number: 900123 |
| 100 SAMPLE ST, ANYTOWN, CO-80000-0000 |
| Home: 555-010-0100 |
| Guarantor: Sample, Pat Q
Insurance: BH COLORADO ACCESS Payer ID: UOACC |
| PCP: Jordan K Rivera |
| Appointment Facility: Brighton Womens Clinic |
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| Past Medical History |
- Current Tobacco Use- about 1 pack per day, started at age 14.
- Generalized Anxiety Disorder.
- Low Back Pain with Right-Sided Sciatica.
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| Surgical History |
- Cyst Removal Right Breast - fibrous tissue 1997
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| Family History |
- Mother: alive 66 yrs, diagnosed with Cancer
- Father: alive 76 yrs, diagnosed with Hypertension
- Siblings: alive, diagnosed with Hypertension
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| Social History |
| Tobacco use |
| Tobacco Status: Current tobacco user pack a day |
| Depression Screening PHQ-2 |
| Screening Test Result Positive - 3 or more |
| Follow Up Plan (required) Schedule f/u with Behavioral Health |
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| Hospitalization/Major Diagnostic Procedure |
- Childbirth x 1 vaginal, uncomplicated
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| History of Present Illness |
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BH Visit Details
BHP conducted a scheduled outreach telephone call as part of
ongoing behavioral health outreach services.
Assessment
Columbia Suicide Severity Rating Scale (C-SSRS): Low Risk.
Outcome Rating Scale (ORS): Score of 4; Clinical.
Plan
No behavioral health follow-up appointment was scheduled at this time.
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| Session Start: 1:00pm. |
| Session End: 2:00pm. |
| Session Duration (Minutes): 60Minutes. |
| Session Setting (PoS) Telehealth |
| Mode of Treatment: Telephone |
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| 1. |
Illness, unspecified - R69 (Primary) |
| 2. |
Generalized anxiety disorder - F41.1 |
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| Labs |
| Lab: BH - Outcome Rating Scale (ORS)
(Collection Date & Time - 06/29/2026) |
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| Procedure Codes |
- H0023 Behavioral Health Outreach Service (TH). Modifiers: GT
- 90791 Psychiatric diagnostic evaluation.
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Care Plan Details
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| Electronically signed by Provider: Morgan Lee Taylor , LPC
on 07/13/2026 at 07:52 PM MDT |
| Sign off status: Completed |
Brighton Womens Clinic
30 S 20TH AVE
BRIGHTON, CO 80601-3705
Tel: 303-655-6180
Fax: 720-685-8714
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