Peace Corps Eating Disorder Treatment Summary Form PC-262-8 (Initial Approval 08/2012

Applicant Name ______________________________________________________________________________________________________________________
(Last, First, Middle Initial)
Date of Birth__________ /__________ /___________ Medical Case Number:________________________________________________

(Mo/Day/Year)
Eating Disorder Treatment

Summary Form
OMB No.: 0420-0550
Expiration Date: 1/31/2014
EATING DISORDER TREATMENT SUMMARY FORM

(Confidential)
The individual below has applied to serve as a Peace Corps Volunteer and has reported a past or active eating disorder. This
form must be completed by the health care provider who has oversight and management of the condition.
Note to the Mental Health Professional: When answering the questions below, please consider that there are many assignments
where the Volunteer may be isolated and exposed to violence and crime, extreme poverty, or inequitable treatment. There may
be limited access to Western-trained mental health professionals and little support for existing or new eating disorder symptoms.
Please answer all questions or the form will be considered incomplete and returned to the applicant.
Privacy Act Notice

This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility
for Peace Corps service and, if you are invited to serve as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps
service. Your disclosure of this information is voluntary; however, your failure to provide this information will result in the rejection of your application to become
a Peace Corps Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the routine uses listed in the Peace Corps System of Records.
Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties.
It may also be disclosed to the Office of Workers Compensation Programs in the Department of Labor in connection with claims under the Federal Employees
Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist or other medical personnel treating you or involved in your treatment
or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/
systemofrecords.pdf.
Burden Statement:
Public reporting burden for this collection of information is estimated to average 105 minutes per applicant and 60 minutes per mental health professional per
response. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW,
Washington, DC, 20526 ATTN: PRA (0420 - 0550). Do not return the completed form to this address.
Peace Corps Eating Disorder Treatment Summary Form
PC-262-8 (Initial approval 08/2012)
Page 1 of 4
Medical Case Number:
Mental Health Specialist:__________________________________________________________________________________________________________________Date:_________________________________

Professional degree:_____________________________________________________________________ License No.:_____________________________________________ State:________________
Address:_________________________________________________________________________________________________________________________________Phone:________________________________________
1. Dates and Frequency of Therapy Sessions:

Date of First Session: __________________________________ Frequency of Sessions:____________________________________________________________________________________________
Date of Last Session: __________________________________ Was this a Final Session? h Y h N
If yes, was termination satisfactory and mutual?_______________________________________________________________________________________________________________________________
2. Diagnoses [DSM IV Codes] (List all diagnoses)

If giving a diagnosis of Eating Disorder not otherwise specified, please list criteria that are NOT evidenced to record a diagnosis
of Anorexia or Bulimia
Working Diagnoses
Date Given
Date Resolved
Current Diagnosis
Axis I:
(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis I:
Axis II:
(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis II:
Axis III:
(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis III:
Axis IV:
(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis IV:
Axis V:
(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis V:
3. Presenting Problem and Precipitating Factors:

4. Symptoms: Please be as specific and comprehensive as possible. Also, please include weight control behavior.
Symptom
Onset
Severity
Duration
Date remitted

Residual symptoms, if present: _________________________________________________________________________________________________________________________________________________________
5. Documentation of Weight Over the Past Three Years:________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Page 2 of 4
6. Course of Treatment:_________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
7. Psychotropic Medications, Current and Present:

Medication and Dosage:_________________________________________________________________________________________________________________________________________________________________
Start Date:___________________________________________________________________________________ End Date:_____________________________________________________________________________
Response to Medication:________________________________________________________________________________________________________________________________________________________________
Medication and Dosage:_________________________________________________________________________________________________________________________________________________________________
Start Date:___________________________________________________________________________________ End Date:_____________________________________________________________________________
Response to Medication:________________________________________________________________________________________________________________________________________________________________
Please continue on reverse side of this page, if necessary
8. Mental Health History

Previous Counseling _
h N/A _
If yes, describe:
Dates if known
DSM Diagnosis if known
Psychiatric Hospitalizations _
h N/A _
If yes, describe:
Dates if known
Location:
Suicide Attempt(s) dates)
Suicidal Gestures (dates)
Suicide Ideation (dates)
h N/A
h N/A
h N/A
If yes, describe:
If yes, describe:
If yes, describe:

Risk of recurrence?
Risk of recurrence?
Risk of recurrence?
h None or unlikely
h None or unlikely
h None or unlikely
h Possible or likely (describe):
h I am unable to assess this
Page 3 of 4
9. Level of Functioning
History
Interpersonal (describe):
Work/Educational (describe):
Current
Interpersonal (describe):
Work/Educational (describe):
10. Prognosis:_____________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
11. Risk of exacerbation or recurrence (please consider issues of isolation, different environments, lack of
structure and social support, and limited control over food)___________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
12. What specific recommendations for eating disorder support do you have regarding the management of this
condition over the next three years? All recommendations will help the Peace Corps determine the appropriate
Volunteer placement_________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
Attach:
Required: Current fasting comprehensive metabolic panel and thyroid function tests (TFTs)
B12, folate and iron, if applicable
Do you have any concerns that would prevent this applicant from completing 27 months of Peace Corps service without
disruption due to an eating disorder? NOTE: Peace Corps service may be in areas that are isolated or have limited access to
Western-trained providers and health care systems. Please check one box below.
h I have no concerns. This applicant, with regard to eating disorders, is healthy enough to complete 27 months of uninterrupted
Peace Corps service provided the above recommendations can be accommodated.
h I am unsure that the applicant can complete 27 months of uninterrupted Peace Corps service due to an eating disorder. I
recommend a period of stabilization for this condition and an updated assessment at a later date. (Describe and include
length of time for stabilization.)____________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________
_ _____________________________________________________________________________________________________________________________________________________________________________________________________
h I do not believe that this applicant is or will be able to complete 27 months of Peace Corps service without disruption due
to an eating disorder.
I certify this information is, in my opinion, an accurate representation of the baseline status of the applicants eating disorder.
Mental Health Professional Signature/Title_______________________________________________________________________________________________________________________________________
Mental Health Professional Name (Print)__________________________________________________________________________________________________________________________________________
Date_____________________________________________________________________________________________________________________________________________________________________________________________________
Page 4 of 4

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Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

Date of Birth__________ /__________ /___________ Medical Case Number:________________________________________________

Eating Disorder Treatment

EATING DISORDER TREATMENT SUMMARY FORM

Privacy Act Notice

Peace Corps Eating Disorder Treatment Summary Form

PC-262-8 (Initial approval 08/2012)

Medical Case Number:

Mental Health Specialist:__________________________________________________________________________________________________________________Date:_________________________________

1. Dates and Frequency of Therapy Sessions:

2. Diagnoses [DSM IV Codes] (List all diagnoses)

(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis I:

(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis II:

(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis III:

(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis IV:

(MM/YY)_____________ (MM/YY)_____________ h ongoing Axis V:

3. Presenting Problem and Precipitating Factors:

5. Documentation of Weight Over the Past Three Years:________________________________________________________________________________________________________

PC-262-8 (Initial approval 08/2012)

Medical Case Number:

7. Psychotropic Medications, Current and Present:

8. Mental Health History

DSM Diagnosis if known

Suicide Attempt(s) dates)

Suicidal Gestures (dates)

Suicide Ideation (dates)

h Possible or likely (describe):

h Possible or likely (describe):

h Possible or likely (describe):

h I am unable to assess this

h I am unable to assess this

h I am unable to assess this

Peace Corps Eating Disorder Treatment Summary Form

PC-262-8 (Initial approval 08/2012)

Medical Case Number:

Peace Corps Eating Disorder Treatment Summary Form

PC-262-8 (Initial approval 08/2012)

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Date of Birth____ / /_ Medical Case Number:__________________________________________

Mental Health Specialist:__________________________________________________________________________________Date:_

(MM/YY)_ (MM/YY)_ h ongoing Axis I:

(MM/YY)_ (MM/YY)_ h ongoing Axis II:

(MM/YY)_ (MM/YY)_ h ongoing Axis III:

(MM/YY)_ (MM/YY)_ h ongoing Axis IV:

(MM/YY)_ (MM/YY)_ h ongoing Axis V: