Provider’s Name (Licensure):____________________________________________________________________________________ Address:______________________________________________________________________State:____________ZIP___________ Telephone #:____________________________Fax #:____________________________Tax ID #:____________________________ Date Provider Wishes Authorization to Start:_____________________Diagnosis:__________________________________________ Number of visits requested:_______________________ RISK ASSESSMENT/PATIENT CLINICAL INFORMATION
SUICIDE: ___________ Not Present___________ Ideation____________ Plan____________ Means____________ Prior Attempt No Harm Contract: _________Yes _________No Date of Last Ideation/attempt:_______________________________ HOMICIDE: __________ Not Present__________ Ideation____________ Plan____________ Means____________ Prior Attempt No Harm Contract: _________Yes _________No Date of Last Ideation/attempt:_______________________________ Mood Disturbances: _____ Depression_____ Mania_____ Hypomania_____ Anxiety Onset:________________________ Behavioral Disturbances: ______Recklessness_____ Impulsiveness______ Decline in functioning Onset:_______________ Eating Disorder Onset:______________________________ Dementia Onset:___________________________________________ Substance Abuse Onset:___________ Other (please give brief description):____________________________________________ Hallucinations: _______________ Auditory_______________ Visual______________ Command Onset:_______________
_______________ Delusions ______________ Paranoia Onset:_______________
PCA 2 font puliti_gao 6 17/05/12 09.47 Pagina 5PCA 2 (2012) ISSN: 2039-7895 (pp. 5-6)P o s t - C l a s s i c a l A r c h a e o l o g i e s EDITORIAL Geographers, historians and archaeologists have long offered compre-hensive analyses of past urban transformations. In so doing, each sep-arate discipline has developed specific theoretical and methodological frame-works and distinct paths of re
Access Statement for Glendevon Guest House Introduction Our guest house is a large Victorian house just off Marine Parade on Ramsgate's East Cliff. We have 6 letting rooms each with their own en suite bath/shower room and fully equipped kitchens allowing guests to prepare and eat meals if they wish. We have 1 double room on the ground floor and the other 5 rooms are upstairs and are
TREATMENT PLAN