The 18-year-old cowered in the corner of a cot pushed against the wall of the school nurse's office, playing with the silver rings on her fingers and thumb.
She looked dazed and listless, her gaunt face framed by long, brown hair.
"Did you eat today? Did you keep it down?" she was asked.
Aleen Hazelip, a member of a mental health emergency response team and a registered nurse who has worked in psychiatric units for 20 years, questioned the girl about her symptoms and desire for treatment.
In response to delicate prodding, the girl said in a barely audible voice that she had recently begun having flashbacks of molestation by her father and cousin. Over the past few months she had lost her appetite and sometimes went days without eating; she had only been sleeping one or two hours a night.
The school nurse had called for help from a mental health emergency response team after the student fainted at school and was taken to her office. The nurse said she had watched the girl deteriorate since August.
After a consultation with the school nurse, Hazelip arranged for the student to be checked for physical problems and referred her to a psychologist who could provide out-patient care, a course of treatment that would be covered by the girl's insurance.
Hazelip's visit to the Santa Ana high school was among hundreds of calls fielded each month by three mental health emergency response teams operating in Orange County.
The teams are something of a psychiatric 911, but they are operated as part of private community outreach programs rather than by public agencies.
The on-site evaluations--often made in an emergency room, at the site of a police crisis, in a school or at a business--are provided at no charge to the party requesting help. Team members are paid by the sponsoring private hospital or mental health center.
When a call for help comes, a team member drives to the psychiatric emergency, assesses the problem and determines a course of action--which might range from involuntary hospitalization to a referral to an out-patient counselor. While team members go to a many locations, they do not go to private homes because of safety concerns. They can arrange to meet someone at a hospital or other location.
The teams, which are on call 24 hours a day, are a mix of registered nurses, licensed social workers, marriage and family counselors and other mental health professionals. All are qualified to institute the involuntary hospitalization of a person who is gravely disabled or presents a danger to self or others. (By law, police officers and county-approved physicians or technicians are authorized to take away a person's liberty for psychiatric evaluation for up to 72 hours.)
The largest of the three programs in the county is operated by Community Psychiatric Centers, which fields 700 to 1,000 calls a month. CPC has three hospitals in Orange County--in Santa Ana, Brea and Laguna Hills--and specializes in mental health and chemical dependency care. Patty Dennis is director of the 40-member Psychiatric Assessment and Triage team.
Also operating a psychiatric evaluation team is College Hospital Costa Mesa. The 12 members of the crisis response team field about 150 calls a month, according to program director Leslie Mills.
The newest team operating in the county, established last summer, is Crisis Care at Yorba Hills Hospital and Mental Health Center. Its seven team members handle about 50 calls a month, said program director Rob Renno.
Determining the course of action in a crisis requires a balance of the patient's level of need, willingness to get help and ability to pay for services, say the program directors.
Getting involved in providing free emergency evaluations has made sense for the hospitals in several ways. It allows them to make their services known to those who need them and can sometimes channel paying patients to the facility that employs the team member.
The program directors are all quick to point out that the response teams make referrals to a variety of mental health providers, not just their own facilities.
While some people in and out of the mental health field are concerned about the potential conflict of interest in having evaluations made by those with a vested interest in attracting patients, others say the teams are providing a much needed service in a time when public agencies are stretched to the limit.
"In general (conflict of interest) is not a problem, but there is a potential to be exploitative," said Dr. Chuck Faltz, chair of the California Psychiatric Assn.'s Hospital Practices Committee. Faltz said that hospitals have suffered with the weak economy and are looking into every possible area to provide added income. The problem, he said, is that most people don't think of hospitals as being for-profit, and it is important that hospitals make clear to patients the costs of service.
Among those who regularly call on the response teams are law enforcement agencies.