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Assessment
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Sources of Risk
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Sources of Risk
• • •
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Sources of Risk Comments
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Suicide Risk Factors
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Suicide Risk Factors
• • •
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Suicide Risk Factor Comments
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Suicide Protective Factors
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Suicide Protective Factors
• • •
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Suicide Protective Factors Comment
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Suicide Prevention Plan
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Addressing Imminent Risk
• • •
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Addressing Diagnoses
• • •
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Addressing Symptoms
• • •
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Addressing Social Factors
• • •
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Diagnosis
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AXIS I
• • •
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AXIS II
• • •
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AXIS IV
• • •
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GAF(CURRENT)
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Other Diagnoses
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Impression
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Impression
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Informed Consent
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Consent Given by Patient
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Name of Informed Consent Individual (not pt)
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Relationship to Pt of Informed Consent Individual
• • •
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Informed Consent Items
• • •
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Benefits and Risks of Medication
• • •
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Counseling and Coordination of Care
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Medication Management Counseling
• • •
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Other Medication Management Counseling
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Diagnosis & Prognosis Counseling
• • •
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Other Diagnosis & Prognosis Counseling
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Patient Self-Management Counseling
• • •
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Other Patient Self-Management Counseling
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Recent Stressors Counseling
• • •
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Other Recent Stressors Counseling
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Coordination of Care
• • •
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Referred patient/caregiver to:
• • •
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Other Resources
• • •
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Smoking Cessation Counseling
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Psychotherapy
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Psychotherapy
• • •
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Psychotherapy Comments
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Psychotherapy Counseling
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