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PERSONAL INFORMATION
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REFERRAL OBJECTIVE
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HEALTH PROFILE
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FINANCIAL AND MEDICAL INFORMATION
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PERSON INFORMATION
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DOCUMENTS AND SUBMISSION
GENDER
MALE
FEMALE
OTHER
N/A
LANGUAGE
ENGLISH
FRENCH
PERSONNE FOR INTERVENTION
MEDICAL DOCTOR
SIGNIFICANT OTHER
ACCOMMODATION
DAY CENTER
EXTERNAL FOLLOW UP
BRIEF DESCRIPTION OF FOLLOW UP
APPLIED RESOURCES AND/OR INTERVENTION
DIAGNOSTIC
NUMBER OF HOSPITALIZATIONS
DATE OF START OF HEALTH CHALLENGES
INTELLECTUAL DEFICIENCY
YES
NO
DEGREE
LIGHT
AVERAGE
HEAVY
COURT ORDER
PHYSICAL CONDITION AND/OR ILLNESSES
PRESENT INFECTIOUS DISEASES
YES
NO
PLEASE INDICATE
VIOLENCE INVOLVING POLICE INTERVENTION
YES
NO
POLICE VERIFICATION AUTHORIZATION
YES
NO
LIVING ENVIRONMENT
FAMILY
AUTONOMOUS
HOSPITALIZATIONS
OTHER
REVENUE SOURCE
DOES THIS PERSON HAVE THE REVENUE TO PAY $19.07 PER NIGHT
YES
NO
PRESCRIPTION MEDICATIONDOSAGE & PRN
ACCEPT AND UNDERSTANDS THE NEED FOR MEDICATION
YES
NO
UNDERSTAND THE MEDICATION AND SIDE AFFECTS
YES
NO
CAN TAKE MEDICATION INDEPENDENTLY
YES
NO
NEEDS FREQUENT P.R.N
YES
NO
HAS CHILDREN
YES
NO
CONTACT WITH FAMILY
YES
NO
PRESENTLY HAS A JOB
YES
NO
WORK SITUATION
SUICIDE RISK
YES
NO
VIOLENCE OR PHYSICAL AGRESSION
YES
NO
COOPERATES GENERALLY WELL
YES
NO
EXPRESS THEIR NEEDS WELL
YES
NO
MOTIVATED BY CHANGE
YES
NO
RECOGNIZES MENTAL ILLNESS
YES
NO
CAN MANAGE OWN BUDGET
YES
NO
RECOGNIZES SYMPTOMS, STRESSERS AND WARNING SIGNS ASSOCIATED TO A RELAPSE OR HARM TO HIMSELF
YES
NO
MAINTAINS A GOOD CONTACT WITH THEIR INTERVENOR
YES
NO
PSYCHIATRIC ASSESSMENT OR/AND CASE SUMMARY
PHYSICAL ÉVALUATION WITHIN THE LAST 6 MONTHS
OTHER
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