mirror-epstein-docs/results/IMAGES009/DOJ-OGR-00025002.json

{
  "document_metadata": {
    "page_number": "549",
    "document_number": "76318-054",
    "date": "07/09/2019",
    "document_type": "Diagnostic and Care Level Formulation",
    "has_handwriting": false,
    "has_stamps": false
  },
  "full_text": "Page 549\n\nBureau of Prisons\nPsychology Services\nDiagnostic and Care Level Formulation\n\n**SENSITIVE BUT UNCLASSIFIED**\n\nInmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nDate: 07/09/2019 10:13\nSex: M\nFacility: NYM\nProvider: [b(6); (b)(7)(C)] PhD/Chief\nReg #: 76318-054\nUnit Team: A&O\n\nRelevant Historical Information\nInmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol.\n\nPresenting Problem/Symptom\nInmate Epstein was seen for suicide risk assessment today for precautionary reasons. He did not mark any mental health items or symptoms on his Psychology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had court proceedings yesterday which could have given him bad news regarding his legal situation. Inmate Epstein was returned from court after duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a formal suicide risk assessment to determine whether he is currently at-risk for suicidality.\n\nDiagnostic Formulation\nInmate Epstein has no history of mental health problems and does not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment and has no history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologically stable and is in no psychological distress. As such, he is being classified as a CCT1-MH inmate at this time. CARE1-MH is indicative of an inmate who either has no identifiable mental illness (Axis I \"No Diagnosis\") or is mildly ill and requires clinical intervention on an as-needed basis.\n\nCare Level Formulation\nCARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention.\n\nDiagnosis:\nNo Diagnosis, No Dx - Current\n\nCompleted by [b(6); (b)(7)(C)] PhD/Chief Psychologist on 07/09/2019 10:32\n\nGenerated 07/09/2019 10:32 by [b(6); (b)(7)(C)] PhD/Chief Bureau of Prisons - NYM\nPage 1 of 1\nDOJ-OGR-00025002",
  "text_blocks": [
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      "type": "printed",
      "content": "Bureau of Prisons\nPsychology Services\nDiagnostic and Care Level Formulation",
      "position": "header"
    },
    {
      "type": "printed",
      "content": "**SENSITIVE BUT UNCLASSIFIED**",
      "position": "header"
    },
    {
      "type": "printed",
      "content": "Inmate Name: EPSTEIN, JEFFREY EDWARD\nDate of Birth: 01/20/1953\nDate: 07/09/2019 10:13\nSex: M\nFacility: NYM\nProvider: [b(6); (b)(7)(C)] PhD/Chief\nReg #: 76318-054\nUnit Team: A&O",
      "position": "top"
    },
    {
      "type": "printed",
      "content": "Relevant Historical Information\nInmate Epstein is a 66-year-old Caucasian male, currently incarcerated on sex trafficking charges. He denied any history of mental health treatment, either on an inpatient or outpatient basis. Inmate Epstein denied any treatment in the past or present with psychotropic medication. He also denied any acute mental health symptoms at this time. Inmate Epstein denied any past or present suicidal ideation, intention or plan. He denied ever engaging in any suicide attempts or self-injurious behavior in the past. Inmate Epstein denied any alcohol or substance abuse. He said it is well-known that he does not even drink alcohol.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Presenting Problem/Symptom\nInmate Epstein was seen for suicide risk assessment today for precautionary reasons. He did not mark any mental health items or symptoms on his Psychology Questionnaire (PSIQ) when he entered the institution. Nonetheless, Inmate Epstein has various risk factors for suicidality including a high profile case with media attention, sex offense/trafficking charges, pre-trial status, and he had court proceedings yesterday which could have given him bad news regarding his legal situation. Inmate Epstein was returned from court after duty hours yesterday evening and staff notified the on-call psychologist. Inmate Epstein was placed on a precautionary psychological observation status until psychology could interview him this morning to conduct a formal suicide risk assessment to determine whether he is currently at-risk for suicidality.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Diagnostic Formulation\nInmate Epstein has no history of mental health problems and does not exhibit suicidality at this time. He has never received inpatient or outpatient mental health treatment and has no history of suicidality. Currently, he does not exhibit any acute psychopathology, is currently psychologically stable and is in no psychological distress. As such, he is being classified as a CCT1-MH inmate at this time. CARE1-MH is indicative of an inmate who either has no identifiable mental illness (Axis I \"No Diagnosis\") or is mildly ill and requires clinical intervention on an as-needed basis.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Care Level Formulation\nCARE1-MH is indicative of an inmate who shows no significant level of functional impairment associated with a mental illness and demonstrates no need for regular mental health intervention.",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Diagnosis:\nNo Diagnosis, No Dx - Current",
      "position": "middle"
    },
    {
      "type": "printed",
      "content": "Completed by [b(6); (b)(7)(C)] PhD/Chief Psychologist on 07/09/2019 10:32",
      "position": "bottom"
    },
    {
      "type": "printed",
      "content": "Generated 07/09/2019 10:32 by [b(6); (b)(7)(C)] PhD/Chief Bureau of Prisons - NYM\nPage 1 of 1\nDOJ-OGR-00025002",
      "position": "footer"
    }
  ],
  "entities": {
    "people": [
      "Jeffrey Edward Epstein"
    ],
    "organizations": [
      "Bureau of Prisons"
    ],
    "locations": [
      "NYM"
    ],
    "dates": [
      "01/20/1953",
      "07/09/2019"
    ],
    "reference_numbers": [
      "76318-054",
      "DOJ-OGR-00025002"
    ]
  },
  "additional_notes": "The document contains redactions, marked as [b(6); (b)(7)(C)], indicating sensitive information has been withheld."
}