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\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid11805927 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh360\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw19 \cellx9952\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh344\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth9864\clshdrawnil \cellx9952\pard\plain \ltrpar\ql \li0\ri0\sa120\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid11218772 Notes: }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid11218772 This form is designed for use with the following }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5071126 Medicare Benefits Schedule (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid11218772 MBS}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5071126 )}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid11218772 
 items. Users should be familiar with the most recent item definitions and requirements.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6566459  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid11218772 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid5334526\charrsid15407465 MBS }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5071126\charrsid15407465 item number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\caps\f1\fs20\insrsid5334526\charrsid15407465 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid5334526\charrsid15407465 2700    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid5334526\charrsid15407465 2701    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid5334526\charrsid15407465 2715    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid5334526\charrsid15407465 2717 }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid15407465    }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid15407465 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12218694\charrsid11218772 This document is }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12218694\charrsid11218772 not}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12218694\charrsid11218772  a referral letter. A referral letter must be sent to any additional providers involved in this }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5071126 M}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12218694\charrsid11218772 ental }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5071126 H}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12218694\charrsid11218772 ealth }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5071126 T}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12218694\charrsid11218772 reatment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5071126 P}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12218694\charrsid11218772 lan.}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12218694 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid11218772\charrsid15407465 Major headings are }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid11218772\charrsid15407465 bold; }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\i\f1\fs20\insrsid11218772\charrsid15407465 prompts to consider lower case. Response fields }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid11218772 can be e}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid11218772\charrsid15407465 
xpand}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid11218772 ed}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid11218772\charrsid15407465  as required}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid11218772 . }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\ul\insrsid11218772\charrsid15407465 Underlined}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid11218772\charrsid15407465  items of either type are mandatory for compliance with Medicare requirements.}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid11218772\charrsid11218772 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid10361851 \trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh344\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth9864\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh344\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh
\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw21 \cellx9952\pard\plain \ltrpar\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5712665 Contact and demographic details}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526 \trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh344\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 
\trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw21 \cellx9952\row \ltrrow}\trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh462\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3752\clshdrawnil \cellx6059\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1267\clshdrawnil \cellx7366\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 GP name}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid11471536 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid5244859 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 GP phone}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid11011689 \cell \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5334526\charrsid11011689 \trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh462\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3752\clshdrawnil \cellx6059\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1267\clshdrawnil \cellx7366\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid5244859 GP }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid5244859 ractice }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid5244859 ame}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid5244859 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 GP fax\cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid11011689 
\trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh462\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3752\clshdrawnil \cellx6059\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1267\clshdrawnil \cellx7366\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh639\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3752\clshdrawnil \cellx6059\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1267\clshdrawnil \cellx7366\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 GP address\cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid2236790 \cell }{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid5334526 Provider number}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid2236790 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid2236790 
\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh639\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3752\clshdrawnil \cellx6059\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1267\clshdrawnil \cellx7366\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh316\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5059\clshdrawnil \cellx7366\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid10516324 Relationship\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid4916476 This pe}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 rson has been my patient since}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid10516324 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid4916476 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid5334526\charrsid4916476 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh316\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5059\clshdrawnil \cellx7366\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh255\trleft8\trkeep\trbrdrt
\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7625\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid10516324 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid11218772 and/or\cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5334526\charrsid4916476 \trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh255\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7625\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh312\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5059\clshdrawnil \cellx7366\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid4916476 
This person has been a patient at this practice since}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid4916476 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5334526\charrsid4916476 \trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh312\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5059\clshdrawnil \cellx7366\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow9\irowband8\ltrrow\ts15\trgaph128\trrh639\trleft8\trkeep\trbrdrt
\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3525\clshdrawnil \cellx5832\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1494\clshdrawnil \cellx7366\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Patient surname}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488 Date of}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526 b}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488 irth}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  (dd/mm/yy)}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid7933488 \trowd \irow9\irowband8\ltrrow\ts15\trgaph128\trrh639\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3525\clshdrawnil \cellx5832\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1494\clshdrawnil \cellx7366\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Patient}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526 first n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488 ame}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5712665 /}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 s}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Preferred name}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid13458047 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid7933488 
\trowd \irow10\irowband9\ltrrow\ts15\trgaph128\trrh639\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3525\clshdrawnil \cellx5832\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1494\clshdrawnil \cellx7366\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2526\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow11\irowband10\ltrrow\ts15\trgaph128\trrh309\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 
\trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7625\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Gender\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  FORMCHECKBOX }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  Female   }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Male}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Self-identified gender:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid2236790 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid2236790 \trowd \irow11\irowband10\ltrrow\ts15\trgaph128\trrh309\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7625\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow12\irowband11\ltrrow\ts15\trgaph128\trrh638\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7625\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Patient a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid7933488 ddress\cell }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid2236790 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid2236790 \trowd \irow12\irowband11\ltrrow\ts15\trgaph128\trrh638\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7625\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow13\irowband12\ltrrow\ts15\trgaph128\trrh638\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3792\clshdrawnil \cellx6099\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3793\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid16059852 Patient phone\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852 Preferred }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852 umber:
\par 
\par 
\par Can leave message?   }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852  Yes    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852  No\cell }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852 Alternative }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852 umber:
\par 
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852 Can leave message?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852   }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid16059852  Yes    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid16059852  No\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid16059852 
\trowd \irow13\irowband12\ltrrow\ts15\trgaph128\trrh638\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3792\clshdrawnil \cellx6099\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3793\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow14\irowband13\lastrow \ltrrow
\ts15\trgaph128\trrh605\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3792\clshdrawnil \cellx6099\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1941\clshdrawnil \cellx8080\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1812\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Medicare }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5712665 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526 o.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Health}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5712665  C}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 are Card/Pension}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5712665 er Concession Card }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5712665 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 o.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow14\irowband13\lastrow \ltrrow\ts15\trgaph128\trrh605\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx2267\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3792\clshdrawnil \cellx6099\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1941\clshdrawnil \cellx8080\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1812\clshdrawnil \cellx9952\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5273251 \page 
\par \ltrrow}\trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh329\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth6338\clcbpatraw21 \cellx6394\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3486\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Carer/support person contact}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833  }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 etails \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl
\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 Has patient consented for }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 this}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 healthcare team to contact carer/support persons}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid6427833 ?\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh329\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth6338\clcbpatraw21 \cellx6394\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3486\clshdrawnil \cellx9952
\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh789\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2369\clshdrawnil \cellx2432\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1872\clshdrawnil \cellx4341\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2017\clshdrawnil \cellx6394\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2212\clshdrawnil \cellx8642\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1234\clshdrawnil \cellx9952\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 First contact:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid9701055 \cell }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 Relationship:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid7933488 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl
\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par 
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Yes
\par 
\par With the following restrictions:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  No\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 
\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh789\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2369\clshdrawnil \cellx2432\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1872\clshdrawnil \cellx4341\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2017\clshdrawnil \cellx6394\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2212\clshdrawnil \cellx8642\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1234\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh
\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2369 \cellx2432\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1872 \cellx4341\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2017 \cellx6394\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2212 \cellx8642\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1234 \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 Second contact:\cell Relationship:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl
\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Yes
\par 
\par With the following restrictions:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  No\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 
\trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2369 \cellx2432\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1872 \cellx4341\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2017 \cellx6394\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2212 \cellx8642\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1234 \cellx9952\row 
\ltrrow}\trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth6298\clcbpatraw21 \cellx6354\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3526 \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 Emergency contact person details\cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Patient }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 consent for healthcare team to contact emergency }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 contacts}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid6427833 ?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt
\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth6298\clcbpatraw21 \cellx6354\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3526 \cellx9952\row \ltrrow
}\trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2329 \cellx2392\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1952 \cellx4381\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1937 \cellx6354\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2135 \cellx8525\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1351 \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 First contact:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid9701055 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833 Relationship:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11218772\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Yes\cell }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833  No\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5712665\charrsid6427833 \trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2329 \cellx2392\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1952 \cellx4381\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1937 \cellx6354\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2135 \cellx8525\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1351 \cellx9952\row 
\ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 Second contact:\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833 Relationship:\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11218772\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Yes\cell }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833  No\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5712665\charrsid6427833 \trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh547\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2329 \cellx2392\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1952 \cellx4381\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1937 \cellx6354\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2135 \cellx8525\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1351 \cellx9952\row 
\ltrrow}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh402\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw21 \cellx9952\pard\plain \ltrpar\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8131242\charrsid6427833 Salient communication and cultural factors}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh402\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5533827\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw21 \cellx9952\row \ltrrow}\trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh402\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3051\clshdrawnil \cellx3131\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1270\clshdrawnil \cellx4439\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5463\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Language spoken at home\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  English}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid656542 \cell }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833  Other:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 
\trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh402\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3051\clshdrawnil \cellx3131\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1270\clshdrawnil \cellx4439\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5463\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Interpreter required}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\delrsid4260315 \cell }{\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526  No\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 , }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8131242 c}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 omments:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid5334526\charrsid6427833 \trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh402\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3051\clshdrawnil \cellx3131\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1270\clshdrawnil \cellx4439\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5463\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Country of birth\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526  Australia\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5334526\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid6427833  Other:\cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow9\irowband8\ltrrow\ts15\trgaph128\trrh402\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3051\clshdrawnil \cellx3131\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1270\clshdrawnil \cellx4439\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5463\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow10\irowband9\ltrrow
\ts15\trgaph128\trrh425\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3029\clshdrawnil \cellx3091\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6795\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid409326\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 Other communication }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid409326 factors}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid10516324 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow10\irowband9\ltrrow\ts15\trgaph128\trrh425\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3029\clshdrawnil \cellx3091\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6795\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow11\irowband10\lastrow \ltrrow\ts15\trgaph128\trrh489\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3029\clshdrawnil \cellx3091\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6795\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid409326\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 Other }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid409326 relevant cultural factors}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid5334526 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid6427833 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid6427833 \trowd \irow11\irowband10\lastrow \ltrrow\ts15\trgaph128\trrh489\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3029\clshdrawnil \cellx3091\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6795\clshdrawnil \cellx9952\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16195810 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526 \page 
\par \ltrrow}\trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid5334526 S \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid8131242 \lquote Subjective\rquote }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid5334526\charrsid10771107 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid10771107 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\row \ltrrow}\trowd \irow1\irowband0\lastrow \ltrrow\ts15\trgaph128\trrh45\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid4283751 Consider:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526\charrsid5799497 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin360\pararsid5334526\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid5334526\charrsid5799497 Reasons for presenting
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 History of current episode
}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid4283751 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526\charrsid5799497 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid5334526\charrsid5799497 Mental health history
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526\charrsid5799497 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Salient}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid5334526\charrsid5799497  social history}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid5334526\charrsid5799497 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526\charrsid5799497 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid5334526\charrsid5799497 Salient medical/biological history}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid5334526\charrsid5799497 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 
Salient developmental issues
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Family history of mental illness/suicidal behaviour}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid4283751 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 
Current domestic and social circumstances, including relationships and occupation}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid4283751 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5334526\charrsid4283751 \loch\af3\dbch\af0\hich\f3 \'b7\tab}S}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526 alient s}
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid4283751 ubstance use issues
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5799497 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin360\pararsid5799497\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5799497 Current and previous medications, including effectiveness and side effects for mental disorders.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15426919 
\par }\pard \ltrpar\s16\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid5799497\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5799497\charrsid5799497 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10647219\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid10647219 

\par 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5799497\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid10647219\charrsid14447178 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid14447178 \trowd \irow1\irowband0\lastrow \ltrrow\ts15\trgaph128\trrh45\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526 \page 
\par \ltrrow}\trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5334526\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid5334526 O \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid5646289 \lquote Objective\rquote }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid5334526\charrsid10771107 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid10771107 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh45\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5334526\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid10647219 Comments on current }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid5334526\charrsid5799497 mental state
}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid5273251\charrsid5799497  examination}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid5334526 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12930570 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5799497\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5799497\charrsid11218772 Consider:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5799497\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls6\adjustright\rin0\lin360\pararsid5799497\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497\charrsid10490134 
Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid5799497\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar\s16\ql \fi-360\li360\ri0\widctlpar\intbl
\tx2985\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls6\adjustright\rin0\lin360\pararsid5799497\yts15\contextualspace {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497\charrsid10490134 
Appropriateness of Mini}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497 -}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497\charrsid10490134 Mental State Examination}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5799497  (MMSE)}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497\charrsid10490134  for patients }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497 aged \u707\'3f}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5799497\charrsid10490134 75 years or if otherwise indicated}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5799497\charrsid5799497 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5799497\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5334526\charrsid5799497 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10647219\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid10647219\charrsid15817493 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid5334526\charrsid14447178 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526\charrsid14447178 \trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh45\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh294\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 Allergies}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526\charrsid2916096 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\tx2985\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5799497\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5334526 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid5334526 \trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh294\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh366\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 Relevant physical examination and other investigations}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid9768410\charrsid7933488 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2985\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5799497\yts15 {\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14447178 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid14447178 \trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh366\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow4\irowband3\lastrow \ltrrow\ts15\trgaph128\trrh498\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 Results of relevant previous psychological and developmental testing}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid9768410\charrsid7933488 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2985\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5799497\yts15 {\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid7933488 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid7933488 \trowd \irow4\irowband3\lastrow \ltrrow\ts15\trgaph128\trrh498\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5334526 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410 \page 
\par \ltrrow}\trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid9768410 A \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid3476568 \lquote Assessment\rquote }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid9768410\charrsid10771107 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid10771107 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh324\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx5026\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1697\clshdrawnil \cellx6763\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx8499\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1677\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid12930570 Risk assessment}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3476568 
 \endash  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14881865 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6708714 I}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 f high level of risk indicated, document actions taken in }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid3476568 the t}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 reatment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3476568 p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12930570 lan below}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12930570 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14881865\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3476568\charrsid11218772 Consider asking:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid14881865\charrsid5966776 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid14881865\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14881865\charrsid5966776 Does the patient have a timeline for acting on a plan?
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid14881865\charrsid5966776 \loch\af3\dbch\af0\hich\f3 \'b7\tab}How bad is the pain/distress experienced?}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14881865\charrsid5966776 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid14881865\charrsid5966776 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid14881865\charrsid5966776 Is it interminable, inescapable, intolerable?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid9768410 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 
Ideation/ thoughts}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 Intent}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 Plan}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 
\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9768410\charrsid14447178 \trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh324\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx5026\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1697\clshdrawnil \cellx6763\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx8499\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1677\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh322\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh
\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx5026\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1697\clshdrawnil \cellx6763\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx8499\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1677\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid9768410 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid9768410\charrsid14970352 Suicide}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid14447178 \trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh322\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl
\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx5026\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1697\clshdrawnil \cellx6763\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx8499\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1677\clshdrawnil \cellx10236\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid9768410 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 Self}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2446951 -}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 harm}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid14447178 \trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh322\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl
\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx5026\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1697\clshdrawnil \cellx6763\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx8499\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1677\clshdrawnil \cellx10236\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid9768410 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14970352 Harm to others}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\delrsid14360678\charrsid14970352 \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid14447178 \trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh322\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl
\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx5026\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1697\clshdrawnil \cellx6763\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx8499\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1677\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh304\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh
\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid9768410 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 Comments or details of any identified risks
}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14447178 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid14447178 \trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh304\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh637\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid9768410 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl
\tx2985\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12930570\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410\charrsid14447178 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid9768410\charrsid14447178 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh637\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh294\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid12930570 Assessment}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9118259\charrsid12930570 /outcome}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid12930570  tool used}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6623306  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6623306\charrsid12930570 
(except where clinically inappropriate)}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9768410 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12930570\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570\charrsid11218772 Include:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid12930570 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid12930570\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570 Date of assessment}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12930570\charrsid9768410 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid12930570 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570 Results}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12930570\charrsid9768410 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570\charrsid14881865 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid808794\charrsid808794 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12930570\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid9768410\charrsid14881865 \cell }\pard\plain \ltrpar
\s16\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid12930570\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14881865\charrsid14881865 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410 \trowd \irow7\irowband6\ltrrow
\ts15\trgaph128\trrh294\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9768410\charrsid12930570 Case formulation and provisional diagnosis of mental health disorder
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12930570\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf22\insrsid9768410 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570\charrsid11218772 Consider asking about:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid12930570\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls7\adjustright\rin0\lin360\pararsid12930570\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570\charrsid10490134 Predisposing factors
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid12930570\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Precipitating factors
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid12930570\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Perpetuating factors
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid12930570\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Protective factors}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12930570 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12930570\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf22\insrsid12930570 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570\charrsid1901100 Consider conditions specified in the }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid12930570\charrsid1901100 International Classification of Primary Care}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12930570 , 2nd edition}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid12930570\charrsid621164 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf22\insrsid12930570\charrsid9768410 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14881865\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid14881865 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14881865\charrsid14881865 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid14881865 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9768410 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9768410 \trowd \irow8\irowband7\lastrow \ltrrow\ts15\trgaph128\trrh294\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410 
\par 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410 \page 
\par \ltrrow}\trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9768410\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid9768410 P \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid13063154 \lquote Plan\rquote }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid9768410\charrsid10771107 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410\charrsid10771107 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid3802170\charrsid6963528 Patient goals
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14167148\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid3802170\charrsid3802170 Setting }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid794755 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14167148 ersonal }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid794755 r}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14167148 ecovery Goals}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6963528 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6963528\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6963528\charrsid11218772 Also consider:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6963528\charrsid16457418 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\sa160\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls8\adjustright\rin0\lin360\pararsid6963528\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 The person themselves prioritising the goal}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 /}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 s to focus on 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6963528 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 T}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 he CHIME framework}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 
 connectedness, hope, identity, meaning and purpose}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418  and empowerment
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6963528 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 W}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 hich strengths are relevant and can be built on to pursue goal}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 /}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 
s 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6963528 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 H}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 ow the person\rquote s values, treatment and support preferences will impact on the action plan 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6963528\charrsid16457418 \loch\af3\dbch\af0\hich\f3 \'b7\tab}
Breaking goals down into smaller manageable steps and making plans for who will do what and when}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528  \endash }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 
 informally or using the SMART (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 pecific, }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 m}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 eaningful, }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 a}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 ttainable, }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 ealistic, }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528 t}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6963528\charrsid16457418 imetabled) approach
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6963528\charrsid16457418 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls8\adjustright\rin0\lin360\pararsid6963528\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6963528\charrsid16457418 Supporting the person to undertake independent or joint actions rather than accepting passive actions}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6963528\charrsid16457418 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14167148\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6963528 
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\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6963528\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15426919\charrsid14167148 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14167148\yts15 {\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid14167148 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14167148 
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\par 
\par 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14167148\charrsid14447178 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid3802170\charrsid6963528 Treatments }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid794755\charrsid6963528 and}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid3802170\charrsid6963528  interventions
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6963528\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid3802170 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid6227530 Consider:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls4\adjustright\rin0\lin360\pararsid6227530\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 Suggested psychological interventions
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Medications
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid3624599 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6227530\charrsid3624599 Key }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 actions to be taken by patients}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid11218772 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid11680713 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6227530\charrsid11680713 Support services}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530  to achieve patient goals
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Role of GP}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6227530\charrsid11680713 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid11680713 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Psycho-education
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 Time frame}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10447855 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 I}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10447855 nternet-based}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530  options:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10447855 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}\pard \ltrpar
\s16\ql \fi-360\li1080\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls4\ilvl1\adjustright\rin0\lin1080\pararsid6227530\yts15\contextualspace {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid13461713  HYPERLINK "https://www.mycompass.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 myCompass}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://thiswayup.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 THIS WAY UP}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "http://www.mindspot.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 MindSpot}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://ecouch.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 e-couch}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://moodgym.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530 m}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 ood}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530 gym}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  

\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713  HYPERLINK "https://www.ment
alhealthonline.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 Mental Health Online}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://www.ontrack.org.au/web/ontrack" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 OnTrack}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6963528\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid6227530\charrsid11680713 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6227530\yts15 {\rtlch\fcs1 \af0 \ltrch\fcs0 \ul\insrsid11680713\charrsid6227530 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid3802170\charrsid6227530 Referrals}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid3802170 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid6227530 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 Consider:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls4\adjustright\rin0\lin360\pararsid6227530\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10490134 Practitioner, service or agency}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530  \endash  }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10490134 referred to whom}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10490134  and }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6227530 for }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid10490134 what
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Specific referral request
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Opinion, planning, treatment
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Case conferences
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Time frame}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6227530\charrsid11218772 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 R}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16605326 eferral to internet mental health programs for education}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid11218772  }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf6\insrsid6227530\charrsid11218772 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}\pard \ltrpar
\s16\ql \fi-360\li1080\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls4\ilvl1\adjustright\rin0\lin1080\pararsid6227530\yts15\contextualspace {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid13461713  HYPERLINK "https://www.mycompass.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 myCompass}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://thiswayup.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 THIS WAY UP}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "http://www.mindspot.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 MindSpot}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://ecouch.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 e-couch}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://moodgym.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530 m}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 ood}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530 gym}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  

\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://www.mentalhealthonline.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid16397513 Mental Health Online}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \af0 \ltrch\fcs0 \f2\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13461713 
 HYPERLINK "https://www.ontrack.org.au/web/ontrack" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs25\f1\fs20\ul\cf17\insrsid6227530\charrsid11680713 OnTrack}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid6227530\charrsid11680713 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid6227530 
\par }\pard\plain \ltrpar\s16\ql \li1080\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin1080\pararsid11680713\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid10447855 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6227530\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid11680713\charrsid6227530 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 
\trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 Role of carer/support person\cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid14447178 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid3802170\charrsid6227530 Intervention/relapse prevention plan}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid3802170\charrsid6227530 

\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid6227530 (if appropriate at this stage)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6227530\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid11218772 Consider asking about:
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid6227530\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 Warning signs from past experiences
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Arrangements to intervene in case of relapse or crisis
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Support services currently in place
\par {\listtext\pard\plain\ltrpar \s16 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6227530\charrsid6227530 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6227530\charrsid6227530 Any past effective strategies}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530\charrsid6227530 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6227530\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid9768410 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12530174\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6227530 
\par }\pard\plain \ltrpar\s16\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid6227530\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12530174 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 
\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth10148\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 Other healthcare providers and service providers involved in patient\rquote s care
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6051353\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid3802170\charrsid11218772 (eg psychologist, psychiatrist, social worker, occupational therapist, other GPs, other medical specialists, case }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12476397 
worker, community mental health services}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid11218772 )}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12476397 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid3802170\charrsid14447178 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth10148\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh225\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 
\trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1663\clshdrawnil \cellx1731\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1944\clshdrawnil \cellx3715\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4354\clshdrawnil \cellx8109\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2067\clshdrawnil \cellx10236\pard\plain \ltrpar
\s16\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\faauto\rin0\lin360\pararsid3802170\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12744408 Role\cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12744408 Name\cell Address\cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 Phone}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12744408 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh225\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1663\clshdrawnil \cellx1731\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1944\clshdrawnil \cellx3715\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4354\clshdrawnil \cellx8109\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2067\clshdrawnil \cellx10236\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 \cell \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 
\trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh225\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1663\clshdrawnil \cellx1731\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1944\clshdrawnil \cellx3715\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4354\clshdrawnil \cellx8109\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2067\clshdrawnil \cellx10236\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 \cell \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 
\trowd \irow9\irowband8\ltrrow\ts15\trgaph128\trrh225\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1663\clshdrawnil \cellx1731\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1944\clshdrawnil \cellx3715\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4354\clshdrawnil \cellx8109\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2067\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow10\irowband9\ltrrow\ts15\trgaph128\trrh225\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth10148\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 
\trowd \irow10\irowband9\ltrrow\ts15\trgaph128\trrh225\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9768410\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth10148\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow11\irowband10\ltrrow\ts15\trgaph128\trrh372\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 
\trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16217098\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw21 \cellx10236\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15426919\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12476397\charrsid16217098 Completing the plan}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid9271148\charrsid16217098   }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\ul\cf6\insrsid3802170\charrsid16217098 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16217098\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid15426919\charrsid11218772 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow11\irowband10\ltrrow\ts15\trgaph128\trrh372\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16217098\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw21 \cellx10236\row \ltrrow}\trowd \irow12\irowband11\ltrrow\ts15\trgaph128\trrh349\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099 On completion of the plan, the GP }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170 may}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099  record (tick boxes below) that }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9271148 they}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099  ha}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid9271148 ve}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099 :
\par 
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9271148 D}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099 iscussed the assessment with the patient
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9271148 D}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099 iscussed all aspects of the plan and the agreed date for review
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9271148 O}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099 
ffered a copy of the plan to the patient and/or their carer (if agreed by patient)
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid214099 Date plan completed}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow12\irowband11\ltrrow\ts15\trgaph128\trrh349\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow13\irowband12\ltrrow\ts15\trgaph128\trrh922\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170\charrsid214099 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid3802170\charrsid14447178 \trowd \irow13\irowband12\ltrrow\ts15\trgaph128\trrh922\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow14\irowband13\ltrrow\ts15\trgaph128\trrh515\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12413529 Plan added to the patient\rquote s records?\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170   Yes
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170   No}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf23\insrsid3802170\charrsid2979215 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 \trowd \irow14\irowband13\ltrrow\ts15\trgaph128\trrh515\trleft8\trkeep\trbrdrt
\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow15\irowband14\lastrow \ltrrow\ts15\trgaph128\trrh793\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3802170\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3802170\charrsid12413529 Copy of the plan offered to other providers?\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170   Yes
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170   No}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf23\insrsid3802170 
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3802170  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b313900000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3802170   Not required}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf23\insrsid3802170\charrsid2979215 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3802170\charrsid14447178 
\trowd \irow15\irowband14\lastrow \ltrrow\ts15\trgaph128\trrh793\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11218772\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth7445\clshdrawnil \cellx7513\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2663\clshdrawnil \cellx10236\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9768410 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 \page 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16217098\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat21\cltxlrtb\clftsWidth3\clwWidth10319\clcbpatraw21 \cellx10407\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8467476 Record of patient consent}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 \trowd \irow0\irowband0\ltrrow
\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16217098\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat21\cltxlrtb\clftsWidth3\clwWidth10319\clcbpatraw21 \cellx10407\row \ltrrow}\trowd \irow1\irowband1\ltrrow
\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10319\clshdrawnil \cellx10407\pard\plain \ltrpar
\ql \li0\ri0\sb120\sa240\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 I, ___________________________________________________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid11218772 
name of patient}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid5322574 , }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 agree to information about my}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  health being recorded in my medical file and being shared between the }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 GP}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2979215\charrsid214099  and other healt}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 hcare providers involved in my}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 
 care, as nominated above, to assist in the management of my healthcare. I understand that I must inform my GP if I wish to change the nominated pe}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 ople involved in my}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  care.  
\par I understand that as part of my}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215  c}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 are under this Mental Health Treatment }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5322574 P}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 lan, I should attend }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 the}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2979215\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 g}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 eneral }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 p}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 racti}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 ce}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  for a review appointment at least }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 four}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 weeks}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid5322574 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  but }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 no longer than six}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2979215\charrsid214099  months}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5322574 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  after the plan has been developed.
\par I consent to the release of the following information to the following carer/support and emergency contact persons:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid14639418 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 \trowd \irow1\irowband1\ltrrow
\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10319\clshdrawnil \cellx10407\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trrh117\trleft8
\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2230\clshdrawnil \cellx2298\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4070\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3939\clshdrawnil \cellx10407\pard\plain \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2979215\charrsid214099 Name\cell }\pard \ltrpar
\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2979215\charrsid214099 Assessment\cell Treatment Plan\cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid2979215\charrsid214099 \trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trrh117\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2230\clshdrawnil \cellx2298\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4070\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3939\clshdrawnil \cellx10407\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts18\trgaph108\trrh116\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh
\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2230\clshdrawnil \cellx2298\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3503\clshdrawnil \cellx5841\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth527\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3386\clshdrawnil \cellx9834\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth513\clshdrawnil \cellx10407\pard\plain \ltrpar
\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid2979215\charrsid214099 \cell }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid2979215\charrsid214099 Yes\cell No\cell Yes\cell No\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215\charrsid214099 \trowd \irow3\irowband3\ltrrow\ts18\trgaph108\trrh116\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2230\clshdrawnil \cellx2298\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3503\clshdrawnil \cellx5841\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth527\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3386\clshdrawnil \cellx9834\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth513\clshdrawnil \cellx10407\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12665039 W}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215 ith the following limitations:
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12589883 W}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215 ith the following limitations:
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 \trowd \irow4\irowband4\ltrrow\ts18\trgaph108\trrh116\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2230\clshdrawnil \cellx2298\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3503\clshdrawnil \cellx5841\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth527\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3386\clshdrawnil \cellx9834\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth513\clshdrawnil \cellx10407\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12589883 W}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 ith the following limitations:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12589883 W}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 ith the following limitations:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 
\par \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid2979215 \trowd \irow5\irowband5\ltrrow\ts18\trgaph108\trrh116\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2230\clshdrawnil \cellx2298\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3503\clshdrawnil \cellx5841\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth527\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3386\clshdrawnil \cellx9834\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth513\clshdrawnil \cellx10407\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt
\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5133\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5214\clshdrawnil \cellx10407\pard\plain \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 
\par __________________________________________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid11218772 Signature of patient\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 ________/________/________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid11218772 Date\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 \trowd \irow6\irowband6\ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5133\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5214\clshdrawnil \cellx10407\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10319\clshdrawnil \cellx10407\pard\plain \ltrpar
\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 
\par I, ____________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 ___________________________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099 _, have discussed the plan and referral}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12589883 /s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid214099  with the patient.
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\tx2210\tx7160\tx12263\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid11218772 Full name of GP}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid12589883 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 \trowd \irow7\irowband7\ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrnone \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10319\clshdrawnil \cellx10407\row \ltrrow}\trowd \irow8\irowband8\lastrow \ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt
\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5133\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5214\clshdrawnil \cellx10407\pard\plain \ltrpar\qr \li0\ri0\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11414666\yts18 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14503543\charrsid15824825 Mental Health Treatment Plan Included:                                                          }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid14503543\charrsid15824825 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14503543\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825 
\par 
\par __________________________________________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid11218772 Signature of GP}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid14503543\charrsid4876654 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid14503543\charrsid15824825      }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14503543\charrsid15824825 No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825          }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  FORMCHECKBOX }
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14503543\charrsid15824825 Yes (if yes, please select below)
\par }\pard \ltrpar\ql \li0\ri0\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14503543\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid14503543\charrsid15824825                         MBS }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12589883 i}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14503543\charrsid15824825 tem }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12589883 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14503543\charrsid15824825 umber}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid14503543\charrsid15824825 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825   
\par                         }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14503543\charrsid15824825 2700    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14503543\charrsid15824825 2701    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14503543\charrsid15824825 2715  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14503543\charrsid15824825 2717 }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825    
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14503543\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12545917\charrsid15824825 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid15824825 _______/________/________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14503543\charrsid11218772 Date}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid14503543\charrsid4876654 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14503543 
\trowd \irow8\irowband8\lastrow \ltrrow\ts18\trgaph108\trrh376\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5133\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5214\clshdrawnil \cellx10407\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16523457 \page 
\par \ltrrow}\trowd \irow0\irowband-1\lastrow \ltrrow\ts15\trgaph128\trrh360\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposy1200\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3
\trpaddfb3\trpaddfr3\tblrsid10379415\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw19 \cellx9952\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posy1200\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10379415\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid13765565\charrsid16523457 Request for services}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid10379415\charrsid16523457 

\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\cf8\insrsid10379415\charrsid16523457 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10379415\charrsid16523457 \trowd \irow0\irowband-1\lastrow \ltrrow\ts15\trgaph128\trrh360\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl
\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposy1200\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3
\trpaddfb3\trpaddfr3\tblrsid10379415\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw19 \cellx9952\row }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16523457 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid16523457\charrsid16523457 
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trrh117\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10647219\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9882\clshdrawnil \cellx9970\pard\plain \ltrpar
\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 Date: }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang3081\langfe2052\langfenp2052\insrsid16523457\charrsid16523457 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid16523457\charrsid16523457 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 To}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13765565 :}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid7343300 Attn}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 ]
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid7343300 Address}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 ]
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid7343300 Post code}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 ]
\par 
\par 
\par Subject:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid16523457\charrsid16523457 \hich\af1\dbch\af31505\loch\f1  L}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 etter}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid16523457\charrsid16523457 
\hich\af1\dbch\af31505\loch\f1  of }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13765565 \hich\af1\dbch\af31505\loch\f1 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid16523457\charrsid16523457 \hich\af1\dbch\af31505\loch\f1 equest for }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13765565 \hich\af1\dbch\af31505\loch\f1 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid16523457\charrsid16523457 \hich\af1\dbch\af31505\loch\f1 ervices
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 
\par 
\par }\pard \ltrpar\qj \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 Dear Dr
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid16523457\charrsid16523457 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 I am referring [patient\rquote s name] for 
\par 
\par I am referring [patient\rquote s name] [date of birth] for [number of sessions] sessions.
\par 
\par I have been [patient\rquote s name]\rquote s primary care physician for the past [number of years] years.
\par 
\par In summary, the following assessment and treatment planning has been undertaken: [  ]
\par 
\par 
\par Mental Health Treatment Plan attached:  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 Yes  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid16523457\charrsid16523457  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 No
\par 
\par Specific treatment requests}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13765565 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457  [  ]
\par 
\par 
\par If you have any questions, please feel free to contact me directly. I will be available on phone [T+00000000] and email [email@email.com] in case of any query.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7343300\charrsid16523457 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 Looking forward to your reply}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13765565 .}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 

\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 Yours sincerely,
\par 
\par 
\par [Signature]\tab }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13765565 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 \tab \tab \tab 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 [Physician\rquote }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 s }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13765565 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 ame}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13765565  and title}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16523457\charrsid16523457 

\par 
\par \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid16523457\charrsid16523457 
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13765565 P}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13765565\charrsid16523457 rovider number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid16523457\charrsid16523457 ]
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 
\par 
\par 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16523457\yts18 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16523457\charrsid16523457 
\par 
\par 
\par 
\par 
\par \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid16523457\charrsid16523457 \trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trrh117\trleft8\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10647219\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9882\clshdrawnil \cellx9970\row }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215 
\par \ltrrow}\trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid7427697 Review}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid2979215\charrsid10771107 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid2979215\charrsid10771107 \trowd \irow0\irowband-1\ltrrow\ts15\trgaph128\trrh405\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6374559\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw19 \cellx10236\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh302\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth10148 \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2979215\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2979215\charrsid7803740 MBS }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid738169\charrsid7803740 
item number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2979215\charrsid7803740 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2979215\charrsid7803740  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740  }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \caps\f1\fs20\insrsid2979215\charrsid7803740 2712    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13461713 
{\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid5334526\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid2979215\charrsid7803740 2719}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid2979215\charrsid2979215 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2979215\charrsid10771107 
\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh302\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth10148 \cellx10236\row \ltrrow}\trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh
\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3789\clshdrawnil \cellx3857\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6319\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid2979215\charrsid12072246 Planned date for review with GP
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6051353\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2979215\charrsid7803740 (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8153956 I}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740 nitial review }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8153956 
four}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8153956\charrsid7803740  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740 weeks to }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8153956 six}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215\charrsid7803740  months after completion of plan)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2979215 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12072246\charrsid7803740 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6374559\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2979215\charrsid7803740 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid2979215\charrsid14447178 \trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3789\clshdrawnil \cellx3857\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6319\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1966214\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid1966214\charrsid12072246 Actual date of review with GP
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12072246\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid15426919\charrsid1966214 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1966214\yts15 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid15426919\charrsid7803740 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1966214\charrsid14447178 \trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3789\clshdrawnil \cellx3857\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6319\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1966214\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid1966214\charrsid12072246 Assessment/outcome tool results on review}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1966214\charrsid1966214  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8153956\charrsid12072246 (except where clinically inappropriate}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8153956 )}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\ul\insrsid1966214\charrsid11218772 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1966214\charrsid7803740 
\par \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15426919\charrsid7803740 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1966214\charrsid14447178 \trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3789\clshdrawnil \cellx3857\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6319\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15426919\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1966214\charrsid9572134 Comments}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8534186  \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid6695424\charrsid12072246 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid8534186\charrsid12072246 eview of patient\rquote 
s progress against goals, checking, reinforcing and expanding education, modification of treatment plan (if required)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15426919 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12072246\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid1966214\charrsid12072246 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1966214\charrsid12072246 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1966214\charrsid14447178 
\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2979215\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3789\clshdrawnil \cellx3857\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6319\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1966214\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
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