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{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fhimajor\f31528\fbidi \froman\fcharset238\fprq2 Cambria CE;}{\fhimajor\f31529\fbidi \froman\fcharset204\fprq2 Cambria Cyr;}{\fhimajor\f31531\fbidi \froman\fcharset161\fprq2 Cambria Greek;}{\fhimajor\f31532\fbidi \froman\fcharset162\fprq2 Cambria Tur;}
{\fhimajor\f31535\fbidi \froman\fcharset186\fprq2 Cambria Baltic;}{\fhimajor\f31536\fbidi \froman\fcharset163\fprq2 Cambria (Vietnamese);}{\fbimajor\f31538\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
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{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}
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{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\fbiminor\f31578\fbidi \fswiss\fcharset238\fprq2 Arial CE;}{\fbiminor\f31579\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}
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\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 \chftnsep 
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\ltrch\fcs0 \insrsid12459122 \chftnsepc 
\par }}{\*\aftnsep \ltrpar \pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid12459122 \chftnsep 
\par }}{\*\aftnsepc \ltrpar \pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid12459122 \chftnsepc 
\par }}\ltrpar \sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}
{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}
{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\ltrrow
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\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16533150\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\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15413402\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\insrsid15413402\charrsid12790559  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid15803385  Patient we}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\cf18\insrsid15803385\charrsid2491319 llbeing assessment}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf18\insrsid15803385\charrsid2491319  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid15803385\charrsid2491319 
and recovery plan}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf18\insrsid15803385\charrsid2491319  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf8\insrsid13388468\charrsid15803385 \endash }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\cf8\insrsid15413402\charrsid15803385  Children and adolescents}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf8\insrsid15413402\charrsid9784082  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\cf8\insrsid13388468\charrsid11805927 \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 \insrsid13388468\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 
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\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16533150\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\tblrsid16533150\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\pararsid15407465\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid15803385 Note}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid15407465\charrsid15803385 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid15803385 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15407465\charrsid15803385  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10516324\charrsid15803385 This form is designed for use with }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15803385 the following }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15413402 
Medicare Benefits Schedule (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15803385 MBS}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15413402 )}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15803385 
 items. Users should be familiar with the most recent item definitions and requirements.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15407465\charrsid15803385 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid13388468\charrsid15407465 MBS }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15413402\charrsid15407465 item number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\caps\f1\fs20\insrsid13388468\charrsid15407465 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid13388468\charrsid15407465 2700    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid13388468\charrsid15407465 2701    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid13388468\charrsid15407465 2715    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid13388468\charrsid15407465 2717 }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid15407465    }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15407465\charrsid15407465 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12999878\charrsid15803385 This document is }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12999878\charrsid15803385 not}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12999878\charrsid15803385  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\insrsid15413402 M}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12999878\charrsid15803385 ental }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15413402 H}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12999878\charrsid15803385 ealth }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15413402 T}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12999878\charrsid15803385 reatment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15413402 P}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12999878\charrsid15803385 lan.}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12999878 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid15803385\charrsid547891 This document is }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\ul\insrsid15803385\charrsid547891 not}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\i\f1\fs20\insrsid15803385\charrsid547891  a referral letter. A referral letter must be sent to any additional providers involved in this mental health treatment plan.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid15803385 \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 \insrsid13388468\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\tblrsid16533150\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\tblrsid15803385\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\pararsid16533150\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12928751 Contact and demographic details}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468 \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 \insrsid13388468 \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\tblrsid15803385\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3532\clshdrawnil \cellx5979\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1919\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 GP name}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536\charrsid11471536 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid11471536\charrsid5244859 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 GP phone}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536\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 
\insrsid818389\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3532\clshdrawnil \cellx5979\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1919\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\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\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536\charrsid5244859 GP }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid11471536\charrsid5244859 ractice }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536\charrsid5244859 ame}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid11471536 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536\charrsid5244859 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 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 
\insrsid818389\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3532\clshdrawnil \cellx5979\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1919\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3532\clshdrawnil \cellx5979\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1919\clshdrawnil \cellx7938\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 GP address\cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536\charrsid2236790 \cell }{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid11471536 Provider number}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536\charrsid2236790 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536\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 \insrsid818389\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3532\clshdrawnil \cellx5979\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1919\clshdrawnil \cellx7938\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh529\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5491\clshdrawnil \cellx7938\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10516324\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\charrsid10516324 Relationship\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\charrsid4916476 This pe}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324 rson has been my patient since}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\charrsid10516324 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\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 \insrsid818389\charrsid4916476 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh529\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5491\clshdrawnil \cellx7938\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7485\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10516324\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid818389\charrsid10516324 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid818389\charrsid15803385 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 \insrsid818389\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7485\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh472\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5491\clshdrawnil \cellx7938\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10516324\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10516324\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\charrsid4916476 
This person has been a patient at this practice since}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10516324\charrsid7933488 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\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 \insrsid818389\charrsid4916476 \trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh472\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5491\clshdrawnil \cellx7938\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth7870\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth953\clshdrawnil \cellx8931\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth961\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6517829 Was patient involved in discuss}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 ion with GP }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6517829 about treatment plan?\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13381200  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13381200  Yes\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid13381200  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13381200  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 \insrsid818389\charrsid13381200 \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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth7870\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth953\clshdrawnil \cellx8931\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth961\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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6517829 Was parent/guardian involved in discussion with GP about }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468 patient\rquote s treatment }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6517829 plan?\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13381200 
 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13381200  Yes\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13381200  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid13381200  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 \insrsid818389\charrsid13381200 \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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth7870\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth953\clshdrawnil \cellx8931\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth961\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow11\irowband10\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3492\clshdrawnil \cellx5939\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1959\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 Patient s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 urname}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid7933488 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7933488 Date of }{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid11471536 b}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7933488 irth}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536 
(dd/mm/yy)}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid818389\charrsid7933488 \trowd \irow11\irowband10\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3492\clshdrawnil \cellx5939\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1959\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\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\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Patient}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7933488  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid11471536 f}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 irst }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7933488 ame}
{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8873703 /}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid7933488 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Preferred }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468 ame}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid13458047 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid818389\charrsid7933488 
\trowd \irow12\irowband11\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3492\clshdrawnil \cellx5939\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1959\clshdrawnil \cellx7938\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1954\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7485\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4796966\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4796966 Gender\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4796966  FORMCHECKBOX }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4796966  Female   }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid4796966\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4796966\charrsid6427833  Male}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4796966    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4796966\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4796966\charrsid6427833  Self-identified gender:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid4796966\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 \insrsid4796966\charrsid2236790 \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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7485\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow14\irowband13\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7485\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 Patient a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536\charrsid7933488 ddress\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536\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 \insrsid11471536\charrsid2236790 \trowd \irow14\irowband13\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7485\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow15\irowband14\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx5812\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4080\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid16059852 Patient phone\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852 Preferred }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852 umber:
\par 
\par 
\par Can leave message? }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8873703 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852   }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852  Yes    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852  No\cell }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852 Alternative }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11471536 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852 umber:
\par 
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852 Can leave message?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852   }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid16059852  Yes    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid11471536\charrsid16059852 
\trowd \irow15\irowband14\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx5812\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4080\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow16\irowband15\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx5812\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2228\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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Medicare }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8873703 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468 o.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 Health}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8873703  C}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 are Card }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8873703 n}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 o.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 
\trowd \irow16\irowband15\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3365\clshdrawnil \cellx5812\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2228\clshdrawnil \cellx8080\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1812\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow17\irowband16\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth5744\clcbpatraw21 \cellx5812\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4080\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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 Parent}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 /g}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 uardian }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 etails \cell Has patient consented for }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 this}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8873703 t}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 reatment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8873703 p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 lan to be release}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid13388468 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833  to parents/guardians?\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 \insrsid13388468\charrsid6427833 
\trowd \irow17\irowband16\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth5744\clcbpatraw21 \cellx5812\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4080\clshdrawnil \cellx9952
\row \ltrrow}\trowd \irow18\irowband17\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808\clshdrawnil \cellx4255\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1517\clshdrawnil \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2879\clshdrawnil \cellx8731\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1161\clshdrawnil \cellx9952\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 First parent/guardian:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid9701055 
\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 Relationship:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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\pararsid16533150\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par 
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  Yes
\par 
\par With the following restrictions:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 
\trowd \irow18\irowband17\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339\clshdrawnil \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808\clshdrawnil \cellx4255\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1517\clshdrawnil \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2879\clshdrawnil \cellx8731\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1161\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow19\irowband18\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339 \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808 \cellx4255\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1517 \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2879 \cellx8731\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1161 \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 Second parent/guardian:\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\pararsid16533150\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  Yes
\par 
\par With the following restrictions:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 
\trowd \irow19\irowband18\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2339 \cellx2407\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808 \cellx4255\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1517 \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2879 \cellx8731\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1161 \cellx9952\row 
\ltrrow}\trowd \irow20\irowband19\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth5744\clcbpatraw21 \cellx5812\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4080 \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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 Emergency contact person details\cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 Patient/parent/guardian consent for healthcare team to contact emergency }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 contacts}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 ?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid6427833 
\trowd \irow20\irowband19\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth5744\clcbpatraw21 \cellx5812\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth4080 \cellx9952\row \ltrrow
}\trowd \irow21\irowband20\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2379 \cellx2447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808 \cellx4295\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1477 \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2629 \cellx8481\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1411 \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 First contact:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid9701055 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\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\pararsid16533150\yts15 
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par \cell }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  Yes\cell }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 \trowd \irow21\irowband20\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2379 \cellx2447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808 \cellx4295\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1477 \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2629 \cellx8481\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1411 \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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 Second contact:\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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\pararsid16533150\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid6427833 Phone number 1:
\par 
\par Phone number 2:
\par \cell }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  Yes\cell }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 \trowd \irow22\irowband21\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2379 \cellx2447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1808 \cellx4295\clvertalt\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1477 \cellx5812\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2629 \cellx8481\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1411 \cellx9952\row 
\ltrrow}\trowd \irow23\irowband22\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\tblrsid15803385\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\pararsid16533150\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 Schooling}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid10516324  (if applicable)}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid6427833 
\trowd \irow23\irowband22\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\tblrsid15803385\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 \irow24\irowband23\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2273\clshdrawnil \cellx2341\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth749\clshdrawnil \cellx3130\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2849\clshdrawnil \cellx6019\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3873\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 Current }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 school l}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 evel\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\highlight7\insrsid13388468\charrsid12593485 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 
Name of }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 chool}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324 /preschool}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 \trowd \irow24\irowband23\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2273\clshdrawnil \cellx2341\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth749\clshdrawnil \cellx3130\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2849\clshdrawnil \cellx6019\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3873\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow25\irowband24\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2273\clshdrawnil \cellx2341\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7551\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 Salient }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid6427833 chool }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11471536 f}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 actors}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15803385\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15803385\charrsid15803385 Consider asking:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid15803385 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin360\pararsid15803385\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 Has there been any p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid6427833 rior disruption to schooling}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 ?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid6427833 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid15803385 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 What is the c}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid6427833 urrent frequency of school attendance}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 ?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15803385\charrsid6427833 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid15803385 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 
What is the patient\rquote s a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid6427833 bility to start and finish homework}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 ?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15803385\charrsid6427833 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid15803385 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 
How are the patient\rquote s p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid6427833 eer relationships}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 ?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15803385\charrsid6427833 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid15803385 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 
Has the patient experienced any b}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid7165091 ullying}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 ?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15803385\charrsid7165091 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid15803385 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 Ha
s the patient experienced any t}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385\charrsid7165091 raumatic school community events}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15803385 ?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid15803385\charrsid15803385 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833 \cell }\pard\plain \ltrpar
\s19\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid15803385\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\insrsid13388468\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 \insrsid13388468\charrsid6427833 
\trowd \irow25\irowband24\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2273\clshdrawnil \cellx2341\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7551\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow26\irowband25\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\tblrsid16533150\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth9864\clshdrawnil \cellx9952\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 Patient/guardian consent to discuss GPMHTP with}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468  the following members of school community:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid6427833 
\trowd \irow26\irowband25\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\tblrsid16533150\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth9864\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow27\irowband26\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid15614999 Role
\cell Name}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4739522 /}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid15614999 s\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11471536\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid15614999 Phone
\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 \insrsid818389\charrsid15614999 \trowd \irow27\irowband26\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow28\irowband27\ltrrow\ts15\trgaph128\trrh433\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  Yes}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Principal}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 \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 \insrsid818389\charrsid6427833 \trowd \irow28\irowband27\ltrrow\ts15\trgaph128\trrh433\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow29\irowband28\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  Yes}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Assistant Principal}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4739522 /}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 \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 
\insrsid818389\charrsid6427833 \trowd \irow29\irowband28\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  Yes}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Teacher}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4739522 /}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 \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 
\insrsid818389\charrsid6427833 \trowd \irow30\irowband29\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  Yes}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 School }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4739522 c}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 ounsellor}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4739522 /}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid6427833 \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 \insrsid818389\charrsid6427833 \trowd \irow31\irowband30\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\row \ltrrow}\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6165918  Yes\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Other\cell \cell }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 \trowd \irow32\irowband31\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1160\clshdrawnil \cellx1228\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2260\clshdrawnil \cellx3528\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth3754\clshdrawnil \cellx7322\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2570\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow33\irowband32\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\tblrsid15803385\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\pararsid16533150\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4739522\charrsid6427833 Salient communication and cultural factors}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid6427833 \trowd \irow33\irowband32\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\tblrsid15803385\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 \irow34\irowband33\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1378\clshdrawnil \cellx4421\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5471\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Language spoken at home\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  FORMCHECKBOX }
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  English}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid656542 \cell }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid6427833  Other:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 
\trowd \irow34\irowband33\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1378\clshdrawnil \cellx4421\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5471\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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Interpreter required}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\delrsid4260315 \cell }{\field\fldpriv{\*\fldinst 
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468  No\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6427833  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 , }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15027228 c}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468 omments:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 
\insrsid818389\charrsid6427833 \trowd \irow35\irowband34\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1378\clshdrawnil \cellx4421\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5471\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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Country of birth\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468  Australia\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\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 \insrsid818389\charrsid6427833 \trowd \irow36\irowband35\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1378\clshdrawnil \cellx4421\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5471\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow37\irowband36\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6889\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12674853\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324 Other communication }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12674853 factors}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid10516324 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10516324\yts15 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid6427833 \trowd \irow37\irowband36\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6889\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow38\irowband37\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6889\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12674853\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10516324\charrsid6427833 Other }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12674853 relevant cultural issues}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid10516324 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10516324\yts15 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid10516324\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 \insrsid10516324\charrsid6427833 \trowd \irow38\irowband37\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\tblrsid15803385\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth2935\clshdrawnil \cellx3003\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6889\clshdrawnil \cellx9952\row 
}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 \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\tblrsid16533150\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\pararsid16533150\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\insrsid15027228\charrsid10771107 Patient}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf6\insrsid2456712\charrsid15945889  }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid15027228\charrsid12790559 wellb}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid15027228 e}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid15027228\charrsid12790559 ing assessment}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf18\insrsid13388468\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 \insrsid13388468\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\tblrsid16533150\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\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\insrsid13388468\charrsid2576375 Reasons for presenting}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid13388468 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2576375\charrsid15803385 Consider asking:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid2576375 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid2576375\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li720\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls18\adjustright\rin0\lin720\pararsid2576375\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid10490134 What are the patient\rquote s current mental health issues?
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid2576375 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375 What r}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid10490134 equests and hopes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375  does the patient have?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid2576375 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid10771107 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid2576375 \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 
\insrsid13388468\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\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\pararsid2576375\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 History of current episode
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid15803385 Consider asking about:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid2576375\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid2576375\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid10490134 Symptom onset, duration, intensity, time course}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid2576375\charrsid10490134  
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2576375\charrsid2576375 \cell }\pard\plain \ltrpar
\s19\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid2576375\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\insrsid13388468\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 \insrsid13388468\charrsid14447178 
\trowd \irow2\irowband1\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\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\pararsid16533150\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 Implications of symptoms on child}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7474755 /adolescent\rquote s}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468  daily activities
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid7098569 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid14447178 \trowd \irow3\irowband2\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh461\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrnone \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\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\insrsid13388468\charrsid2576375 Patient }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid11471536\charrsid2576375 h}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid13388468\charrsid2576375 istory
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375 Consider:}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12201781\charrsid6384604 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\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 \insrsid13388468\charrsid14447178 
\trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh461\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrnone \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh341\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236{\listtext
\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6384604\charrsid2576375 \loch\af3\dbch\af0\hich\f3 \'b7\tab}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid2576375\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid6384604\charrsid2576375 Mental health history}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid1785750\charrsid2576375 
\par }\pard \ltrpar\s19\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid15803385\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6384604\charrsid7165091 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6384604\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 \insrsid6384604\charrsid14447178 
\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh341\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh362\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236{\listtext
\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6384604\charrsid2576375 \loch\af3\dbch\af0\hich\f3 \'b7\tab}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid2576375\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid6384604\charrsid2576375 Salient social history
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid1785750\charrsid2576375 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6384604\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 
\insrsid6384604\charrsid14447178 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh362\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh521\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236{\listtext
\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid2576375 \loch\af3\dbch\af0\hich\f3 \'b7\tab}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid2576375\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid7165091\charrsid2576375 Salient medical/biological history
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid2576375\charrsid2576375 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2576375\charrsid2576375 \u9792\'3f  \endash  menarche, me}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3434991 nstruation, pregnancy}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid2576375 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid1785750\charrsid2576375 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid2576375 \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 
\insrsid7165091\charrsid14447178 \trowd \irow7\irowband6\ltrrow\ts15\trgaph128\trrh521\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh325\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\s19\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid15803385\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid10779032 Salient deve}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid12201781 lopmental issues}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid6384604 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid14447178 
\trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh325\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow9\irowband8\ltrrow\ts15\trgaph128\trrh1230\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Family history of mental illness
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2576375\charrsid13572716 Consider asking}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375  about:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid2576375 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid2576375\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin360\pararsid2576375\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2576375\charrsid10490134 Family history of suicidal behaviour
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid2576375\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Genogram
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2576375\charrsid7165091 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid2576375\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid2576375 \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 \insrsid7165091\charrsid14447178 \trowd \irow9\irowband8\ltrrow\ts15\trgaph128\trrh1230\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow10\irowband9\ltrrow\ts15\trgaph128\trrh1820\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Current domestic and social circumstances
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid13572716 Consider asking}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942  about:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1853942 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin360\pararsid1853942\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 L}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid10771107 iving arrangements}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid9849850 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 Siblings
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid16059852 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid16059852 Custodial }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid16059852 rrangements
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid16059852 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Social relationships
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid7165091 Engagement with peers}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid13135746 \cell }\pard\plain \ltrpar
\s19\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid1853942\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\insrsid7165091\charrsid7165091 \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 \insrsid7165091\charrsid14447178 
\trowd \irow10\irowband9\ltrrow\ts15\trgaph128\trrh1820\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\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\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Salient substance use issues
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid13572716 Consider asking}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942  about:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1853942 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls4\adjustright\rin0\lin360\pararsid1853942\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 Nicotine use
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Alcohol use
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Illicit substances
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid1853942 Is patient willing to address the issues?\cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid1853942 \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 \insrsid7165091\charrsid14447178 
\trowd \irow11\irowband10\ltrrow\ts15\trgaph128\trrh1820\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow12\irowband11\ltrrow\ts15\trgaph128\trrh891\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Current medications
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid13572716 Consider asking}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942  about:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1853942 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid1853942\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 Dosage, date of commencement, date of change in dosage
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Reason for the prescription 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid13718279 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid13718279 Are there other practitioners involved in the prescription of medication?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid1853942 Are there issues with compliance or misuse?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid1853942 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid1853942 \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 \insrsid7165091 \trowd \irow12\irowband11\ltrrow
\ts15\trgaph128\trrh891\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow13\irowband12\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 History of medication and other treatments for mental illness
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid2962803 Consider asking about:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid15803385 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid5988159 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid1853942\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid5988159 School counselling and }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 other }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid5988159 school interventions}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Past referrals}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid5988159 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 E}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid6162171 ffectiveness of previous treatments}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1853942\charrsid9703717 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 Side effects and 
complications associated with previous treatments}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1853942\charrsid1010279 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid1853942 Patient\rquote s preference for medications}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1853942\charrsid1853942 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid7165091 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid1853942 \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 \insrsid7165091 \trowd \irow13\irowband12\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\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\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid7933488 A}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 llergies
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid2916096 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \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 \insrsid7165091 \trowd \irow14\irowband13\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow15\irowband14\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Relevant physical examination and other investigations}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7165091\charrsid7933488 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid14447178 \trowd \irow15\irowband14\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow16\irowband15\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Results of relevant previous psychological and developmental testing}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7165091\charrsid7933488 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow16\irowband15\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow17\irowband16\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid7933488 Other care plan}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1853942\charrsid1853942 E.g.}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1853942  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid12796156  GP Management Plans and Team Care Arrangements}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 ; 
\par Wellness Recovery Action Plan}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid7933488 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 
 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091  Yes, }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4815486 s}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 pecify:  
\par  
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2409\tx2976\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid7165091  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check27}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091  No }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7165091 
  
\par 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow17\irowband16\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow18\irowband17\ltrrow\ts15\trgaph128\trrh484\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\tblrsid1853942\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\pararsid7165091\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 Comments on }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13178117 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 trengths and }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13178117 p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7165091\charrsid6624386 ositive }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13178117 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 ispositions}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid7165091\charrsid13388468 \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 \insrsid7165091\charrsid13388468 \trowd \irow18\irowband17\ltrrow\ts15\trgaph128\trrh484\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\tblrsid1853942\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 \irow19\irowband18\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid2962803 Consider asking about:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid15803385 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls20\adjustright\rin0\lin360\pararsid1853942\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 A}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid8472141 bilities, talents and interests}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid1853942\charrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 C}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid8472141 ompetencies and accomplishments }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1853942\charrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 P}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid8472141 revious self-help strategies used and those available in the family support network }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1853942\charrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942 S}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid8472141 ervice system and the community at large}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid8472141 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid8472141 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid1853942 \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 \insrsid7165091\charrsid11553098 \trowd \irow19\irowband18\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow20\irowband19\ltrrow\ts15\trgaph128\trrh484\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\tblrsid1853942\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\pararsid7165091\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6384604 Comments on }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid15100152 c}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6384604 urrent }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid15100152\charrsid1853942 m}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid7165091\charrsid1853942 ental }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid15100152\charrsid1853942 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid7165091\charrsid1853942 tate }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid15100152\charrsid1853942 e}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid7165091\charrsid1853942 xamination}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6384604 
\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 \insrsid7165091\charrsid7933488 \trowd \irow20\irowband19\ltrrow\ts15\trgaph128\trrh484\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\tblrsid1853942\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 \irow21\irowband20\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7600\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid15803385 Consider:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid1853942\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls21\adjustright\rin0\lin360\pararsid1853942\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1853942\charrsid10490134 Appearance, cognition, thought process, thought content, attention, 
memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1853942\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid2841257 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid8472141 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2985\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 \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 \insrsid7165091\charrsid7933488 \trowd \irow21\irowband20\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7600\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow22\irowband21\ltrrow\ts15\trgaph128\trrh484\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\tblrsid1853942\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\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\pararsid7165091\yts15 
\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 Trauma}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid131300 -i
}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 nformed }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid131300 c}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 are and }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid131300 p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 ractice (TICP) assessment}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid7165091\charrsid15206503 
\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 \insrsid7165091\charrsid15206503 \trowd \irow22\irowband21\ltrrow\ts15\trgaph128\trrh484\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\tblrsid1853942\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw21 \cellx10236\row \ltrrow}\trowd \irow23\irowband22\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid6624386 Consid}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8472141 er possible influence of trauma}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10619775\charrsid8472141 Trauma can be defined as:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls22\adjustright\rin0\lin360\pararsid10619775\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 E}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 xposure to death
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 T}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 hreatened death
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 A}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 ctual serious injury 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 T}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 hreatened serious injury
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 A}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 ctual sexual violence 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 T}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 hreatened sexual violence\cell }{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid8472141 \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 \insrsid7165091\charrsid15206503 \trowd \irow23\irowband22\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth3476\clshdrawnil \cellx3544\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth6632\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow24\irowband23\ltrrow\ts15\trgaph128\trrh120\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\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\insrsid7165091\charrsid10619775 Risk assessment}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7165091\charrsid15803385  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid685870 \endash  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid15803385 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12390741 I}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 f high level of risk indicated, document actions taken in }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid685870 t}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 reatment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid685870 p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7165091\charrsid14970352 lan below 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid8472141 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid685870\charrsid15803385 Consider asking:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid5966776 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid8472141\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid5966776 Does the patient have a timeline for acting on a plan?
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\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\insrsid8472141\charrsid5966776 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid5966776 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid7868626\yts15\contextualspace {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141\charrsid5966776 Is it interminable, inescapable, intolerable?}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8472141\charrsid15803385 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 
Ideation/thoughts}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 Intent}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7165091\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 Plan}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow24\irowband23\ltrrow\ts15\trgaph128\trrh120\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow25\irowband24\ltrrow\ts15\trgaph128\trrh120\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 Suicide}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow25\irowband24\ltrrow\ts15\trgaph128\trrh120\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\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\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 Self-harm}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid7165091\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow26\irowband25\ltrrow\ts15\trgaph128\trrh120\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow27\irowband26\ltrrow\ts15\trgaph128\trrh479\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\clshdrawnil \cellx10236\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 
\af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 
Harm to others}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\delrsid14360678\charrsid14970352 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow27\irowband26\ltrrow\ts15\trgaph128\trrh479\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx4417\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth2084\clshdrawnil \cellx6541\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth1801\clshdrawnil \cellx8382\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth1794\clshdrawnil \cellx10236\row \ltrrow}\trowd \irow28\irowband27\ltrrow\ts15\trgaph128\trrh299\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7600\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \cell Comments or details of any identified risks\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 \insrsid7165091\charrsid7933488 
\trowd \irow28\irowband27\ltrrow\ts15\trgaph128\trrh299\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7600\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow29\irowband28\ltrrow\ts15\trgaph128\trrh787\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7600\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 \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 \insrsid7165091\charrsid7933488 \trowd \irow29\irowband28\ltrrow\ts15\trgaph128\trrh787\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth2508\clshdrawnil \cellx2576\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth7600\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow30\irowband29\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\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\insrsid7165091\charrsid10619775 Assessment/outcome tool used}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid15803385 ,}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid5469674  
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5469674\charrsid10619775 (}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid10619775 except where clinically inappropriate}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid5469674\charrsid10619775 )}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775\charrsid8472141 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls6\adjustright\rin0\lin360\pararsid10619775\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid8472141 e.g., Strengths and Difficulties Questionnaire
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775\charrsid8472141 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Note: K-10 is not validated for minors
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid10619775 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid8472141 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 {\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid14970352 
\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 \insrsid7165091\charrsid7933488 \trowd \irow30\irowband29\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\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\pararsid7165091\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\insrsid7165091\charrsid10619775 Date of assessment
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid1785750\charrsid8472141 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1769727\yts15 {\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\ul\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow31\irowband30\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow32\irowband31\ltrrow\ts15\trgaph128\trrh776\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\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\insrsid7165091\charrsid10619775 Results
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid7165091\charrsid14970352 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\yts15 {\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 
\par 
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid14970352 Copy of completed tool provided to referred }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 practitioner}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\ul\insrsid7165091\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 \insrsid7165091\charrsid7933488 \trowd \irow32\irowband31\ltrrow\ts15\trgaph128\trrh776\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow33\irowband32\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7165091\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\insrsid7165091\charrsid10619775 Provisional diagnosis of mental health disorder
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 C}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid14970352 onsider conditions specified in the ICPC, including:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid7165091\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 Anxiety co-morbid with }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2490988 a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 utism
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid9393046 ADD/ADHD
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Conduct }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 isorder
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Oppositional }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 efiant }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid9393046 isorder
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Mood }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 isorder
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Separation }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 nxiety
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Phobias
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 Elective m}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 utism
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 Reactive a}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 ttachment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 isorder
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Nonorganic enuresis and encopresis
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Eating }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 isorder
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Adjustment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid9393046 isorder (eg grief/loss/}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid9393046 parental separation/trauma/medical condition)
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Depression
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid9393046 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Anxiety
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid2838399 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid2838399 Unexplained }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid2838399 omatic }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid2838399 isorder
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid2838399 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Mental }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 d}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid2838399 isorder not otherwise specified}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid11955880 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10619775 \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 \insrsid7165091\charrsid7933488 
\trowd \irow33\irowband32\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\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\pararsid7165091\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\insrsid7165091\charrsid10619775 Case formulation}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid1785750\charrsid10619775 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 C}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid2838399 onside}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2490988 r asking about}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid16480422 :
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid7165091\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091 Predisposing factors
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid16323633 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid16323633 Precipitating factors
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid16323633 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Perpetuating factors}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid7165091\charrsid14970352 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7165091\charrsid14970352 Protective factors}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1785750  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid14970352 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid10619775 \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 \insrsid7165091\charrsid7933488 
\trowd \irow34\irowband33\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\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\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091 Other relevant information from carer/informants
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 C}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid2838399 onside}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775 r asking about:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid10619775 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls24\adjustright\rin0\lin360\pararsid10619775\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid10490134 Specific concerns of carer/family
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Impact on carer/family
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Contextual information from members of patient\rquote s community

\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid10619775\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Other content from individuals other than the patient}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10619775\charrsid10619775 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid8472141 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid10619775 \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 \insrsid7165091\charrsid7933488 \trowd \irow35\irowband34\ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\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\pararsid7165091\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7165091\charrsid13388468 Any other comments\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10619775\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7165091\charrsid14360678 \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 \insrsid7165091\charrsid7933488 \trowd \irow36\irowband35\lastrow \ltrrow\ts15\trgaph128\trrh484\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\tblrsid5315967\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 
\cltxlrtb\clftsWidth3\clwWidth4349\clshdrawnil \cellx4417\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf20 \cltxlrtb\clftsWidth3\clwWidth5759\clshdrawnil \cellx10236\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 \sect }\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj \ltrrow\trowd \irow0\irowband0\ltrrow\ts23\trgaph108\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\tblrsid16533150\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth15644\clcbpatraw19 \cellx15390\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\cf18\insrsid12204863 Personal r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid9789522\charrsid11946008 ecovery plan}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid13388468\charrsid16533150 \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 \insrsid13388468 
\trowd \irow0\irowband0\ltrrow\ts23\trgaph108\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\tblrsid16533150\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth15644\clcbpatraw19 \cellx15390\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts23\trgaph108\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth9264\clshdrawnil \cellx15390\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid13388468 \cell \cell }\pard \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid745315\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315 Actions}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid745315\charrsid13388468 \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 \insrsid745315 \trowd \irow1\irowband1\ltrrow\ts23\trgaph108\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth9264\clshdrawnil \cellx15390\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts23\trgaph108\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3079\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3008\clshdrawnil \cellx12323\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3097\clshdrawnil \cellx15390\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid13388468\charrsid13388468 Identified issues/problems}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9399836\charrsid9399836 Consider:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls8\adjustright\rin0\lin360\pararsid8472141\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 As presented by patient
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Developed during consultation
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Formulated by GP
\par }\pard \ltrpar\s19\ql \li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid8472141\yts23\contextualspace {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid745315 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid13388468\charrsid9399836 Goals
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4748270 Consider:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid8472141\charrsid4748270 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls8\adjustright\rin0\lin360\pararsid8472141\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 Goals made in collaboration with patient
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}What does the patient want to see as an outcome from this plan?

\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Wellbeing, function, occupation, relationships
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Any reference to special outcome measures
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Time frame}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13388468\charrsid3624599 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid13388468\charrsid4748270 Treatments}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid14249401\charrsid4748270  & i}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid745315\charrsid4748270 nterventions}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid13388468\charrsid4748270 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4748270 Consider:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid8472141\charrsid10490134 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls9\adjustright\rin0\lin360\pararsid8472141\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 Suggested psychological interventions
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Medications
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Key actions to be taken by patient 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Support services to achieve patient goals
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Role of GP
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Psycho-education
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Time frame
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Internet-based options}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12204863 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}\pard \ltrpar
\s19\ql \fi-360\li1080\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls25\ilvl1\adjustright\rin0\lin1080\pararsid8472141\yts23\contextualspace {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://www.mycompass.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 myCompass}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://thiswayup.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 THIS WAY UP}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "http://www.mindspot.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 MindSpot}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://ecouch.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 e-couch}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://moodgym.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid12204863 m}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 ood}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid12204863 gym}}}\sectd \ltrsect\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://www.mentalhealthonline.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 Mental Health Online}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://www.ontrack.org.au/web/ontrack" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid8472141 OnTrack}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\insrsid12999878\charrsid8472141 
\par }\pard \ltrpar\s19\ql \li1080\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1080\pararsid8472141\yts23\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid8472141 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid13388468\charrsid4748270 Referrals
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4748270 Consider:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls9\adjustright\rin0\lin360\pararsid8472141\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 Practitioner, service or agency}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12204863  \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141\charrsid10490134 referred to whom and what for
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Specific referral request
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Opinion, planning, treatment
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Case conferences
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Time frame
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Referral to internet mental health programs for education}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12204863 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}\pard \ltrpar
\s19\ql \fi-360\li1080\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls9\ilvl1\adjustright\rin0\lin1080\pararsid8472141\yts23\contextualspace {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://www.mycompass.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 myCompass}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://thiswayup.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 THIS WAY UP}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "http://www.mindspot.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 MindSpot}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://ecouch.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 e-couch}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://moodgym.anu.edu.au/welcome" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid12204863 m}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 ood}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid12204863 gym}}}\sectd \ltrsect\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141\charrsid16397513  
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://www.mentalhealthonline.org.au/" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid16397513 Mental Health Online}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid16397513  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f2\fs22\lang3081\langfe3081\langfenp3081 \loch\af2\dbch\af0\hich\f2 \'ad\tab}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12459122 
 HYPERLINK "https://www.ontrack.org.au/web/ontrack" }}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \cs26\f1\fs20\ul\cf17\insrsid8472141\charrsid9438081 OnTrack}}}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid9438081 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16533150\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid3624599 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid745315\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid745315\charrsid3624599 Any r}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid3624599 ole of carer/support person(s)}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8472141\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4748270 Consider:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid8472141 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls9\adjustright\rin0\lin360\pararsid8472141\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 Identified role or task}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11023622 /}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 s }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11023622 (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 eg monitoring, intervention, support}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11023622 )}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Discussed, agreed, }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid4748270\charrsid10490134 and negotiated}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8472141\charrsid10490134  with carer?
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Any necessary supports for carer
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid8472141\charrsid10490134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Time frame}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid745315\charrsid3624599 \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 \insrsid13388468 \trowd \irow2\irowband2\ltrrow\ts23\trgaph108\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3079\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3008\clshdrawnil \cellx12323\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3097\clshdrawnil \cellx15390\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts23\trgaph108\trrh1331\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3079\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3008\clshdrawnil \cellx12323\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3097\clshdrawnil \cellx15390\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid745315\charrsid724893 Issue 1:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12922352 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \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 \insrsid745315 \trowd \irow3\irowband3\ltrrow
\ts23\trgaph108\trrh1331\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3079\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3008\clshdrawnil \cellx12323\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3097\clshdrawnil \cellx15390\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid745315\charrsid724893 Issue 2:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12922352 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid745315 \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 \insrsid745315 \trowd \irow4\irowband4\ltrrow
\ts23\trgaph108\trrh1331\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3079\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3008\clshdrawnil \cellx12323\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3097\clshdrawnil \cellx15390\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid745315\charrsid12871205 Issue 3:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12871205 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12871205 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12871205 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12871205 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1785750\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid745315\charrsid12871205 \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 \insrsid745315\charrsid12871205 
\trowd \irow5\irowband5\ltrrow\ts23\trgaph108\trrh1331\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3096\clshdrawnil \cellx3083\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3204\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3079\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3008\clshdrawnil \cellx12323\clvertalt\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3097\clshdrawnil \cellx15390\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts23\trgaph108\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6340\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9264\clshdrawnil \cellx15390\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12871205\charrsid4748270 Intervention/relapse prevention plan}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12871205\charrsid15803385  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205\charrsid4748270 (if appropriate at this stage)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid745315 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4748270\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4748270\charrsid15803385 Consider asking about:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid4748270 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls27\adjustright\rin0\lin360\pararsid4748270\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4748270 Warning signs from past experiences
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid4748270 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Arrangements to intervene in case of relapse or crisis
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid4748270 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Support services currently in place
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid4748270 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Any past effective strategies}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid4748270\charrsid16457418 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid4748270 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4748270\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205\charrsid14227599 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid745315\charrsid4748270 \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 \insrsid745315\charrsid12871205 \trowd \irow6\irowband6\ltrrow\ts23\trgaph108\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\tblrsid12871205\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6340\clshdrawnil \cellx6233\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9264\clshdrawnil \cellx15390\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts23\trgaph108\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9459\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6145\clshdrawnil \cellx15390\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7015358\yts23 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12871205\charrsid4748270 Psycho-education }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid14249401\charrsid4748270 provided if not already addressed}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid7015358\charrsid4748270  in }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid2907639\charrsid4748270 \lquote 
T}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid7015358\charrsid4748270 reatments and interventions}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid2907639\charrsid4748270 \rquote }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid7015358\charrsid4748270  above?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12871205\charrsid4748270 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4748270\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid1769727\charrsid4748270 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12871205 \tab \tab }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205  No
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1769727\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14227599\charrsid12871205 \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 
\insrsid12871205\charrsid12871205 \trowd \irow7\irowband7\ltrrow\ts23\trgaph108\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9459\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6145\clshdrawnil \cellx15390\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid12871205 Plan added to the patient\rquote s records?\cell }{\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205 \tab \tab }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205\charrsid14970352 
 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\lndscpsxn\pgwsxn16838\pghsxn11906\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid13388468\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12871205  No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12871205\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 \insrsid12871205\charrsid12871205 \trowd \irow8\irowband8\lastrow \ltrrow\ts23\trgaph108\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth9459\clshdrawnil \cellx9311\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6145\clshdrawnil \cellx15390\row }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid10572654 \sect }\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj \ltrrow\trowd \irow0\irowband0\ltrrow\ts23\trgaph108\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\tblrsid10572654\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10289\clshdrawnil \cellx10377\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12871205 Other healthcare providers and service providers involved in patient\rquote s care
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15803385\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 (eg }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14249401\charrsid15803385 p}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 sychologist, }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401\charrsid15803385 p}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 sychiatrist, }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401\charrsid15803385 s}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 ocial }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401\charrsid15803385 w}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 orker, }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14249401\charrsid15803385 o}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 ccupational}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401\charrsid15803385  t}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid15803385 herapist, other GPs, other medical specialists, case worker, community mental health services)\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 \insrsid12871205 \trowd \irow0\irowband0\ltrrow
\ts23\trgaph108\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\tblrsid10572654\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10289\clshdrawnil \cellx10377\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts23\trgaph108\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\tblrsid10572654\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2021\clshdrawnil \cellx2089\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2318\clshdrawnil \cellx4447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth4275\clshdrawnil \cellx8762\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1555\clshdrawnil \cellx10377\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12871205 Role}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid6631826 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205 Name}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12871205\charrsid6631826 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205 Address}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid11232730 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12871205 Phone}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205\charrsid6631826 \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 \insrsid12871205 \trowd \irow1\irowband1\ltrrow\ts23\trgaph108\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\tblrsid10572654\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2021\clshdrawnil \cellx2089\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2318\clshdrawnil \cellx4447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth4275\clshdrawnil \cellx8762\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1555\clshdrawnil \cellx10377\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid12871205 \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 \insrsid12871205 \trowd \irow2\irowband2\ltrrow\ts23\trgaph108\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\tblrsid10572654\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2021\clshdrawnil \cellx2089\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2318\clshdrawnil \cellx4447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth4275\clshdrawnil \cellx8762\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1555\clshdrawnil \cellx10377\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid12871205 \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 \insrsid12871205 \trowd \irow3\irowband3\lastrow \ltrrow\ts23\trgaph108\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\tblrsid10572654\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2021\clshdrawnil \cellx2089\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2318\clshdrawnil \cellx4447\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth4275\clshdrawnil \cellx8762\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1555\clshdrawnil \cellx10377\row }\pard \ltrpar
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts23\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\tblrsid4748270\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat21\cltxlrtb\clftsWidth3\clwWidth10289\clcbpatraw21 \cellx10377\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4748270\yts23 \cbpat21 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\ul\insrsid2240770\charrsid4748270 Completing the plan }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1769727\delrsid3748279\charrsid15817493  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\cf6\insrsid1769727\charrsid4748270 
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1769727\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid1769727\charrsid8918960 \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 \insrsid214099 
\trowd \irow0\irowband0\ltrrow\ts23\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\tblrsid4748270\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat21\cltxlrtb\clftsWidth3\clwWidth10289\clcbpatraw21 \cellx10377\row \ltrrow}\trowd \irow1\irowband1\ltrrow
\ts23\trgaph108\trrh361\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7616\clshdrawnil \cellx7684\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2633\clshdrawnil \cellx10377\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099 On completion of the plan, the GP }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7015358 may}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099  record (tick boxes below) that }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2240770 they}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7015358\charrsid214099  ha}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2240770 ve}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099 :
\par 
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7015358\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2240770 D}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099 iscussed the assessment with the patient
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7015358\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2240770 D}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\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\insrsid7015358\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid7015358\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2240770 O}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099 ffered a copy of the plan to the patient and/or t
heir carer (if agreed by patient)
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7015358\charrsid214099 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7015358\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid7015358\charrsid214099  Date plan completed}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\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 \insrsid7015358 \trowd \irow1\irowband1\ltrrow
\ts23\trgaph108\trrh361\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7616\clshdrawnil \cellx7684\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2633\clshdrawnil \cellx10377\row \ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts23\trgaph108\trrh690\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7616\clshdrawnil \cellx7684\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2633\clshdrawnil \cellx10377\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7015358\charrsid214099 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7015358\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 \insrsid7015358 \trowd \irow2\irowband2\lastrow \ltrrow\ts23\trgaph108\trrh690\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\tblrsid7015358\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth7616\clshdrawnil \cellx7684\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl
\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2633\clshdrawnil \cellx10377\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12871205 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts23\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\tblrsid4748270\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\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid1775474 Record of consent}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\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 \insrsid214099 \trowd \irow0\irowband0\ltrrow\ts23\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\tblrsid4748270\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
\ts23\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\tblrsid214099\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\pararsid14639418\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 I, }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid1775474 ___________________________________________________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 [}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid15803385 name of patient or }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14037283\charrsid15803385 parent/}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid214099\charrsid15803385 guardian}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14037283\charrsid15803385  as applicable}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid214099\charrsid1775474 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  agree to information about my/my charge\rquote s health being recorded in my medical file and being shared between the }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 GP}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  and other healthcare providers involved in my/his/her care, as nominated above, to assist in the management of my}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401 /my charge\rquote s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  healthcare. I 
understand that I must inform my GP if I wish to change the nominated people involved in my/my charge\rquote s care.  
\par I understand that as part of my}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401 /my charge\rquote s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  care under this Mental Health Treatment }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid1775474 P}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 lan, I}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401 /he/she}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid214099\charrsid214099  should attend }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401 the}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 
g}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 eneral }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 racti}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid1775474 ce}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  for a review appointment at least }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 four}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid1775474\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 weeks}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid214099\charrsid214099  but }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 no later than}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 
six}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 months}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1775474 ,}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099\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\insrsid1775474 .}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\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 \insrsid214099 \trowd \irow1\irowband1\ltrrow\ts23\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\tblrsid214099\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\ts23\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\tblrsid214099\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\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid214099\charrsid214099 Name\cell }\pard \ltrpar
\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid214099\charrsid214099 Assessment\cell Treatment }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid2900714 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid214099\charrsid214099 lan\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 \insrsid214099\charrsid214099 \trowd \irow2\irowband2\ltrrow\ts23\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\tblrsid214099\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\ts23\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\tblrsid214099\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\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid214099\charrsid214099 \cell }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid214099\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid214099\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 \insrsid214099\charrsid214099 \trowd \irow3\irowband3\ltrrow\ts23\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\tblrsid214099\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\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2900714 W}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099 ith the following limitations:
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2900714 W}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099 ith the following limitations:
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\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 \insrsid214099 \trowd \irow4\irowband4\ltrrow\ts23\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\tblrsid214099\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\pararsid214099\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2900714 W}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 ith the following limitations:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2900714 W}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 ith the following limitations:
\par \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\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 \insrsid214099 \trowd \irow5\irowband5\ltrrow\ts23\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\tblrsid214099\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\ts23\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\tblrsid8549485\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\pararsid9061984\yts23 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099 
\par __________________________________________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid15803385 Signature of patient or guardian\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 ________/________/________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid15803385 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 \insrsid214099 \trowd \irow6\irowband6\ltrrow\ts23\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\tblrsid8549485\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\ts23\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\tblrsid14639418\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\pararsid9061984\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 
\par I, ____________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8549485 ___________________________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 _, have discussed the plan and referral}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid9775841 /}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid214099 s with the patient.
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\tx2210\tx7160\tx12263\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid9061984\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8549485\charrsid15803385 Full name of GP}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid214099\charrsid9775841 \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 \insrsid214099 \trowd \irow7\irowband7\ltrrow\ts23\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\tblrsid14639418\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\ts23\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\tblrsid8549485\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\pararsid3672357\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3672357\charrsid14116751 Mental Health Treatment Plan }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9775841 i}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid3672357\charrsid14116751 ncluded:                                                          }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid3672357\charrsid14116751 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3672357\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751 
\par 
\par __________________________________________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid15803385 Signature of GP}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid3672357\charrsid11427265 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751 
     }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid3672357\charrsid14116751 No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751          }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid3672357\charrsid14116751 Yes (if yes, please select below)
\par }\pard \ltrpar\ql \li0\ri0\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3672357\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid3672357\charrsid14116751                         MBS }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9775841 i}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3672357\charrsid14116751 tem }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9775841 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid3672357\charrsid14116751 umber}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid3672357\charrsid14116751 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751   
\par                         }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid3672357\charrsid14116751 2700    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid3672357\charrsid14116751 2701    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid3672357\charrsid14116751 2715  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid3672357\charrsid14116751 2717 }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751    
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3672357\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid14116751 ________/________/________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3672357\charrsid15803385 Date}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid3672357\charrsid11427265 \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 \insrsid3672357 
\trowd \irow8\irowband8\lastrow \ltrrow\ts23\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\tblrsid8549485\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 \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\tposy1230\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3
\trpaddfb3\trpaddfr3\tblrsid4537963\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\posy1230\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12390741\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\insrsid12390741\charrsid13379383 R}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid12390741 e}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\cf18\insrsid12390741\charrsid13379383 quest for services}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid13521052\charrsid12390741 
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posy1230\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4537963\tscfirstrow\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\cf8\insrsid13521052\charrsid13521052 \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 \insrsid13521052\charrsid13521052 \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\tposy1230\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3
\trpaddfb3\trpaddfr3\tblrsid4537963\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 \irow0\irowband0\lastrow \ltrrow\ts23\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\tblrsid7474755\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\pararsid13521052\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid13521052\charrsid13521052 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 Date: }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang3081\langfe2052\langfenp2052\insrsid13521052\charrsid13521052 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid13521052\charrsid13521052 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 To}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid11427265 :}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid4748270 Attn}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 ]
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid4748270 Address}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 ]
\par [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid4748270 Post code}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 ]
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 
\par Subject:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13521052\charrsid13521052 \hich\af1\dbch\af31505\loch\f1  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13521052\charrsid13521052 \hich\af1\dbch\af31505\loch\f1 L}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 etter}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13521052\charrsid13521052 
\hich\af1\dbch\af31505\loch\f1  of }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid11427265 \hich\af1\dbch\af31505\loch\f1 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13521052\charrsid13521052 \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\insrsid11427265 \hich\af1\dbch\af31505\loch\f1 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid13521052\charrsid13521052 \hich\af1\dbch\af31505\loch\f1 ervices
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 
\par 
\par }\pard \ltrpar\qj \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 Dear Dr
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid13521052\charrsid13521052 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 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\insrsid13521052\charrsid13521052  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 
650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 Yes  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13521052\charrsid13521052  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 No
\par 
\par Specific treatment requests}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16325850 :}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052  [  ]
\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 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16325850\charrsid13521052 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 Looking forward to your reply}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16325850 .}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid13521052\charrsid13521052 
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 Yours sincerely,
\par 
\par 
\par 
\par [Signature]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16325850 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 \tab \tab \tab \tab 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 [Physician\rquote }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 s }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16325850 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 ame}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16325850  and title}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid13521052\charrsid13521052 

\par 
\par \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13521052\charrsid13521052 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid13521052\charrsid13521052 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid13521052\charrsid4748270 [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10117142\charrsid4748270 Provider number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid13521052\charrsid4748270 ]
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13521052\charrsid13521052 
\par 
\par 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13521052\charrsid13521052 
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13521052\charrsid13521052 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15803385\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13521052\charrsid13521052 
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13521052\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13521052\charrsid13521052 
\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 \insrsid13521052\charrsid13521052 \trowd \irow0\irowband0\lastrow \ltrrow\ts23\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\tblrsid7474755\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 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9061984 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts23\trgaph108\trrh363\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth10712\clcbpatraw19 \cellx10458\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4213569\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\cf18\insrsid6431544\charrsid4213569 Review}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf18\insrsid4213569\charrsid4213569 \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 \insrsid4213569 \trowd \irow0\irowband0\ltrrow
\ts23\trgaph108\trrh363\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth10712\clcbpatraw19 \cellx10458\row \ltrrow}\trowd \irow1\irowband1\ltrrow
\ts23\trgaph108\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14249401\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10712\clshdrawnil \cellx10458\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14249401\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14249401 MBS }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15860969 item number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401\charrsid14249401    }
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401\charrsid15224224  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid14249401\charrsid15224224  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid14249401 2712 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid14249401\charrsid15224224  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14249401  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid14249401\charrsid15224224  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401\charrsid15224224  FORMCHECKBOX }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12459122 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401\charrsid15224224  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14249401\charrsid15224224 2719}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401 \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 \insrsid14249401 \trowd \irow1\irowband1\ltrrow\ts23\trgaph108\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl
\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14249401\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10712\clshdrawnil \cellx10458\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts23\trgaph108\trleft8\trbrdrt
\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5017\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb
\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5607\clshdrawnil \cellx10458\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4213569\yts23 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569 Planned date for review with GP
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4213569\charrsid12196617 (}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4993051 I}{
\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4213569\charrsid12196617 nitial review }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4993051 four}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4213569\charrsid12196617  weeks to }{
\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4993051 six}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4993051\charrsid12196617  }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid4213569\charrsid12196617 months after completion of plan)}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569 \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 \insrsid4213569 \trowd \irow2\irowband2\ltrrow\ts23\trgaph108\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr
\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5017\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb
\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5607\clshdrawnil \cellx10458\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4213569\yts23 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid11881551\charrsid11881551 Actual date of review with GP}{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \f1\fs20\ul\cf6\insrsid1769727\delrsid3748279\charrsid11881551  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid1769727\charrsid11881551 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11881551\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid1785750 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11881551 \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 \insrsid4213569 \trowd \irow3\irowband3\ltrrow\ts23\trgaph108\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr
\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5017\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb
\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5607\clshdrawnil \cellx10458\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4213569\yts23 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid4213569\charrsid11881551 As}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid16610385\charrsid11881551 sessment}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8223002\charrsid11881551 /outcome}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid16610385\charrsid11881551 
 tool results on review}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid4213569\charrsid11881551 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16539669\charrsid11881551 (}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6752538\charrsid11881551 except where clinically inappropriate}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid16539669\charrsid11881551 )}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid6752538\charrsid11881551 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569 
\par \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11881551\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1785750\charrsid4213569 \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 \insrsid4213569 
\trowd \irow4\irowband4\ltrrow\ts23\trgaph108\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5017\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb
\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5607\clshdrawnil \cellx10458\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11881551\yts23 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14227599\charrsid9572134 Comments}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14227599  }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid7803740 Consider:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551\charrsid9572134 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls5\adjustright\rin0\lin360\pararsid11881551\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid11881551\charrsid9572134 Progress on goals and actions
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 Identified actions have}
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid7803740  been }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 initiated and followed through (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid7803740 
e.g. referrals, appointments, attendance}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 )
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551\charrsid5257806 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid11881551\charrsid5257806 Checking, reinforcing and expanding education
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551\charrsid7803740 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid11881551\charrsid7803740 Communication}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551  between the GP and patient}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid7803740 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551\charrsid7803740 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Where appropriate, communication received from referred practitioners}
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551\charrsid5257806 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid11881551\charrsid5257806 Modification of treatment plan if required
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\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11881551 \cell }\pard\plain \ltrpar\s19\ql \li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid11881551\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569 \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 \insrsid4213569 \trowd \irow5\irowband5\ltrrow
\ts23\trgaph108\trleft8\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth1\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4213569\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5017\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb
\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5607\clshdrawnil \cellx10458\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4213569\yts23 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid4213569\charrsid11881551 Intervention/relapse prevention plan}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid4213569\charrsid12871205  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4213569\charrsid11881551 (if appropriate)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11881551\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 Consider:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid4213569 
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\s19\ql \fi-360\li360\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls8\adjustright\rin0\lin360\pararsid11881551\yts23\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 W}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid7803740 arning signs from past experiences
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 A}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid7803740 rrangements to intervene in case of relapse or crisis
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551\charrsid7803740 \loch\af3\dbch\af0\hich\f3 \'b7\tab}Other support services currently in place
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid11881551 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 A}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid14227599 ny past effective strategies
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11881551\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11881551\charrsid15803385 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4213569\charrsid11881551 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
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\b\f1\fs20\insrsid7690874 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8286817 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid214099\charrsid12871205 
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