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Assessment Completed
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Strengths
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Has family support
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Family Support Details
• • •
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Has social support
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Social Support Details
• • •
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Has mental health support.
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Mental Health Support Details
• • •
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Has medical Health Support
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Medical Health Support Details
• • •
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Has education/Vocational Support
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Education/Voc/Employment Support Details
• • •
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Has employment/Financial Support
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Employment/Financial Support Details
• • •
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Has spirituality support
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Spiritual Support Details
• • •
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strengths notes
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Other/Notes
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Needs
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Basic Needs
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Does client has access to food.
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client has access to homeless shelter
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Does client have access to clothing
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client has access to Recreational/Socialization
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Does client has access to housing
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client has access to transportation
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Are there protective services involved
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Legal Services
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Is client in need of advocacy
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Does client need financial assistance
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Other/Notes
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Other/Notes
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Health Needs
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client has access to primary care
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Medication Assistance (financial)
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dental care
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Health Educational and Prevention
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client has access to therapy
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residential inpatient services
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Alcohol and Drug Abuse Treatment
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client has access to self help support groups
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Risky Behavior for Hep C & HIV (testing)
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Other/Notes
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Employment/Vocational
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General Educational Development (GED)
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College degree
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career assessment
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job skills training
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Other/Notes
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Therapist
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Discharge Type
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Summary
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Narrative
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Therapist
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Therapists
• • •
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Goals & Objectives
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Goals
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Objectives
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Completed Goals
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Other/Notes
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ELECTRONIC SIGNED FIELD
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signed by pin#
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signed by pin#
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