Erie County Department of Human Services Office of MH/MR
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Confidential Survey

The Erie County Office of Mental Health/Mental Retardation would like to collect information about problems that persons with mental illness, who need medication, might be having at their pharmacy when they try to get their prescriptions filled, now that the State laws have changed.

Some of the changes include:

• Persons with mental illness cannot receive more than one medication in the same “class.” For example, some people cannot receive two anti-depression medications. Examples of anti-depression medications are Effexor (Venlafaxine), Lexapro (Escitalopram), Zoloft (Sertraline), Paxil (Proxetine), and Prozac (Fluoxetine Hydrochloride).

• Some adults are not able to get their “stimulant” medication prescription filled. Examples of stimulant medications are Concerta (Methylphenidate Tab), Strattera (Atomoxetine), Adderall (Amphetamine Sulfate), and Vyvanse (Lisdexamfetamine Dimesylate).

• Some children under age 18 cannot get their “anti-psychotic” prescription filled. Examples of anti-psychotic medications are Geodon (Ziprasidone HCL), Risperdal (Risperidone), and Abilify (Aripiprazole).

• People may not be able to receive more than six medications at one time, whether this be for physical health and/or behavioral health.

You can fill in this form yourself if you have had difficulty getting a prescription(s) filled, or you can have someone fill in the form for you.

1. Name of person completing this form:

Name of person completing this form:

2. Relationship (such as mother, father, blended case manager, high risk case manager, etc.):

Relationship (such as mother, father, blended case manager, high risk case manager, etc.):

3. Consumer Name:

Consumer Name:

4. Do you have an Access Card?

Do you have an Access Card? Yes

5. List the name of the medication that you are having a problem getting filled, or re-filled. Next to the medication, describe what happens to you, and how you feel, without the medication.

For Example-

• Medication: Xanax

• Description: I am unable to fall asleep, I feel jittery when I am in a large crowd of people.

List the name of the medication that you are having a problem getting filled, or re-filled. Next to the medication, describe what happens to you, and how you feel, without the medication. For Example- • Medication: Xanax • Description: I am unable to fall asleep, I feel jittery when I am in a large crowd of people. Medication 1:
Description:
Medication 2:
Description:
Medication 3:
Description:
Medication 4:
Description:

6. Please write anything else that you would want to pass on about the difficulty you had getting your prescription filled, or how you feel in general since you have not had your medication.

Please write anything else that you would want to pass on about the difficulty you had getting your prescription filled, or how you feel in general since you have not had your medication.

7. Would you like to talk to a staff person at the Erie County Office of Mental Health about what you have written?

Would you like to talk to a staff person at the Erie County Office of Mental Health about what you have written? Yes

8. If you answered yes, please enter your phone number:

If you answered yes, please enter your phone number:

You or the person who completed this survey can contact Lori Lutterbaugh (814-451-6844) or Wendy Jacobs (814-451-6822) with questions or for assistance.

If you print the survey and fill it out manually, please return to Lori Lutterbaugh or Wendy Jacobs at:

Erie County Department of Human Services
Office of Mental Health, 4th Floor
154 W. 9th Street
Erie, PA 16501

Surveys can also be faxed to 814-451-6868, or sent via email to Lori.

Erie County Department of Human Services Office of MH/MRExit this survey

Confidential Survey

Erie County Department of Human Services Office of MH/MR
Exit this survey