{\rtf1\adeflang1025\ansi\ansicpg1252\uc1\adeff0\deff0\stshfdbch31506\stshfloch31506\stshfhich31506\stshfbi31507\deflang3081\deflangfe3081\themelang3081\themelangfe0\themelangcs1037{\fonttbl{\f0\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f1\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}
{\f2\fbidi \fmodern\fcharset0\fprq1{\*\panose 02070309020205020404}Courier New;}{\f3\fbidi \froman\fcharset2\fprq2{\*\panose 05050102010706020507}Symbol;}{\f10\fbidi \fnil\fcharset2\fprq2{\*\panose 05000000000000000000}Wingdings;}
{\f34\fbidi \froman\fcharset0\fprq2{\*\panose 02040503050406030204}Cambria Math;}{\f39\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}{\f142\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604030504040204}Tahoma;}
{\flomajor\f31500\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fdbmajor\f31501\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fhimajor\f31502\fbidi \froman\fcharset0\fprq2{\*\panose 00000000000000000000}Cambria;}{\fbimajor\f31503\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\flominor\f31504\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fdbminor\f31505\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fhiminor\f31506\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}{\fbiminor\f31507\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}{\f281\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\f282\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\f284\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f285\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f286\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\f287\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\f288\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f289\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f291\fbidi \fswiss\fcharset238\fprq2 Arial CE;}
{\f292\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}{\f294\fbidi \fswiss\fcharset161\fprq2 Arial Greek;}{\f295\fbidi \fswiss\fcharset162\fprq2 Arial Tur;}{\f296\fbidi \fswiss\fcharset177\fprq2 Arial (Hebrew);}
{\f297\fbidi \fswiss\fcharset178\fprq2 Arial (Arabic);}{\f298\fbidi \fswiss\fcharset186\fprq2 Arial Baltic;}{\f299\fbidi \fswiss\fcharset163\fprq2 Arial (Vietnamese);}{\f301\fbidi \fmodern\fcharset238\fprq1 Courier New CE;}
{\f302\fbidi \fmodern\fcharset204\fprq1 Courier New Cyr;}{\f304\fbidi \fmodern\fcharset161\fprq1 Courier New Greek;}{\f305\fbidi \fmodern\fcharset162\fprq1 Courier New Tur;}{\f306\fbidi \fmodern\fcharset177\fprq1 Courier New (Hebrew);}
{\f307\fbidi \fmodern\fcharset178\fprq1 Courier New (Arabic);}{\f308\fbidi \fmodern\fcharset186\fprq1 Courier New Baltic;}{\f309\fbidi \fmodern\fcharset163\fprq1 Courier New (Vietnamese);}{\f621\fbidi \froman\fcharset238\fprq2 Cambria Math CE;}
{\f622\fbidi \froman\fcharset204\fprq2 Cambria Math Cyr;}{\f624\fbidi \froman\fcharset161\fprq2 Cambria Math Greek;}{\f625\fbidi \froman\fcharset162\fprq2 Cambria Math Tur;}{\f628\fbidi \froman\fcharset186\fprq2 Cambria Math Baltic;}
{\f629\fbidi \froman\fcharset163\fprq2 Cambria Math (Vietnamese);}{\f671\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\f672\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\f674\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}
{\f675\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}{\f676\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\f677\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\f678\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}
{\f679\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\f1701\fbidi \fswiss\fcharset238\fprq2 Tahoma CE;}{\f1702\fbidi \fswiss\fcharset204\fprq2 Tahoma Cyr;}{\f1704\fbidi \fswiss\fcharset161\fprq2 Tahoma Greek;}
{\f1705\fbidi \fswiss\fcharset162\fprq2 Tahoma Tur;}{\f1706\fbidi \fswiss\fcharset177\fprq2 Tahoma (Hebrew);}{\f1707\fbidi \fswiss\fcharset178\fprq2 Tahoma (Arabic);}{\f1708\fbidi \fswiss\fcharset186\fprq2 Tahoma Baltic;}
{\f1709\fbidi \fswiss\fcharset163\fprq2 Tahoma (Vietnamese);}{\f1710\fbidi \fswiss\fcharset222\fprq2 Tahoma (Thai);}{\flomajor\f31508\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\flomajor\f31509\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbmajor\f31518\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbmajor\f31519\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\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;}
{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\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;}
{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\fhiminor\f31573\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}
{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\fbiminor\f31578\fbidi \fswiss\fcharset238\fprq2 Arial CE;}{\fbiminor\f31579\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}
{\fbiminor\f31581\fbidi \fswiss\fcharset161\fprq2 Arial Greek;}{\fbiminor\f31582\fbidi \fswiss\fcharset162\fprq2 Arial Tur;}{\fbiminor\f31583\fbidi \fswiss\fcharset177\fprq2 Arial (Hebrew);}
{\fbiminor\f31584\fbidi \fswiss\fcharset178\fprq2 Arial (Arabic);}{\fbiminor\f31585\fbidi \fswiss\fcharset186\fprq2 Arial Baltic;}{\fbiminor\f31586\fbidi \fswiss\fcharset163\fprq2 Arial (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;
\red0\green255\blue255;\red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;\red128\green0\blue128;\red128\green0\blue0;
\red128\green128\blue0;\red128\green128\blue128;\red192\green192\blue192;\chyperlink\ctint255\cshade255\red0\green0\blue255;\cfollowedhyperlink\ctint255\cshade255\red128\green0\blue128;\cbackgroundone\ctint255\cshade255\red255\green255\blue255;
\ctexttwo\ctint255\cshade255\red31\green73\blue125;\red236\green233\blue216;\cbackgroundone\ctint255\cshade242\red242\green242\blue242;\red255\green255\blue255;\ctextone\ctint255\cshade255\red0\green0\blue0;}{\*\defchp 
\f31506\fs22\lang3081\langfe1033\langfenp1033 }{\*\defpap \ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 }\noqfpromote {\stylesheet{
\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 \snext0 \sqformat \spriority0 \styrsid13388468 Normal;}{\*\cs10 
\additive \ssemihidden \sunhideused \spriority1 Default Paragraph Font;}{\*
\ts11\tsrowd\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv \ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang3081\langfe1033\cgrid\langnp3081\langfenp1033 \snext11 \ssemihidden \sunhideused Normal Table;}{\*\ts15\tsrowd
\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv 
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 \sbasedon11 \snext15 \styrsid13388468 Table Web 2;}{\*
\ts15\tsrowd\tsbrdrdgl\brdrnil\tsbrdrdgr\brdrnil \rtlch\fcs1 \af0 \ltrch\fcs0 \tscfirstrow Table Web 2;}{\*\cs16 \additive \rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16 \sbasedon10 \ssemihidden \sunhideused \styrsid13388468 annotation reference;}{
\s17\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 
\sbasedon0 \snext17 \slink18 \ssemihidden \sunhideused \styrsid13388468 annotation text;}{\*\cs18 \additive \rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang0\langfe3081\langfenp3081 \sbasedon10 \slink17 \slocked \ssemihidden \styrsid13388468 
Comment Text Char;}{\s19\ql \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 
\sbasedon0 \snext19 \slink29 \sqformat \spriority34 \styrsid13388468 List Paragraph;}{\s20\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af142\afs16\alang1025 \ltrch\fcs0 
\f142\fs16\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 \sbasedon0 \snext20 \slink21 \ssemihidden \sunhideused \styrsid13388468 Balloon Text;}{\*\cs21 \additive \rtlch\fcs1 \af142\afs16 \ltrch\fcs0 \f142\fs16\lang0\langfe3081\langfenp3081 
\sbasedon10 \slink20 \slocked \ssemihidden \styrsid13388468 Balloon Text Char;}{\s22\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af1\afs24\alang1025 \ltrch\fcs0 \f1\fs24\cf1\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 
\snext22 \spriority0 \styrsid13388468 Default;}{\*\ts23\tsrowd\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv 
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang3081\langfe1033\cgrid\langnp3081\langfenp1033 \sbasedon11 \snext23 \spriority59 \styrsid13388468 
Table Grid;}{\s24\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs20\alang1025 \ltrch\fcs0 \b\fs20\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 
\sbasedon17 \snext17 \slink25 \ssemihidden \sunhideused \styrsid4213569 annotation subject;}{\*\cs25 \additive \rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \b\f0\fs20\lang0\langfe3081\langfenp3081 \sbasedon18 \slink24 \slocked \ssemihidden \styrsid4213569 
Comment Subject Char;}{\*\cs26 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \ul\cf17 \sbasedon10 \sunhideused \styrsid2243126 Hyperlink;}{\*\ts27\tsrowd\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 
\trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv 
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 \sbasedon11 \snext15 \styrsid8725552 Table Web 21;}{\*
\ts27\tsrowd\tsbrdrdgl\brdrnil\tsbrdrdgr\brdrnil \rtlch\fcs1 \af0 \ltrch\fcs0 \tscfirstrow Table Web 21;}{\*\ts28\tsrowd\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv
\brdrs\brdrw10 \trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv 
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af31507\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang3081\langfe1033\cgrid\langnp3081\langfenp1033 \sbasedon11 \snext23 \spriority59 \styrsid8725552 
Table Grid1;}{\*\cs29 \additive \rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\lang0\langfe3081\langfenp3081 \sbasedon10 \slink19 \slocked \spriority34 \styrsid7748850 List Paragraph Char;}{\*\cs30 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \ul\cf18 
\sbasedon10 \ssemihidden \sunhideused \styrsid16461790 FollowedHyperlink;}}{\*\listtable{\list\listtemplateid-1172779234\listhybrid{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat2\levelspace0\levelindent0{\leveltext
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\leveltemplateid201916419\'01o;}{\levelnumbers;}\f2\fbias0\hres0\chhres0 \fi-360\li1080\lin1080 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\lvltentative\levelspace0\levelindent0{\leveltext\leveltemplateid201916421
\'01\u-3929 ?;}{\levelnumbers;}\f10\fbias0\hres0\chhres0 \fi-360\li1800\lin1800 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\lvltentative\levelspace0\levelindent0{\leveltext\leveltemplateid201916417
\'01\u-3913 ?;}{\levelnumbers;}\f3\fbias0\hres0\chhres0 \fi-360\li2520\lin2520 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\lvltentative\levelspace0\levelindent0{\leveltext\leveltemplateid201916419\'01o;}{\levelnumbers
;}\f2\fbias0\hres0\chhres0 \fi-360\li3240\lin3240 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\lvltentative\levelspace0\levelindent0{\leveltext\leveltemplateid201916421\'01\u-3929 ?;}{\levelnumbers;}
\f10\fbias0\hres0\chhres0 \fi-360\li3960\lin3960 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\lvltentative\levelspace0\levelindent0{\leveltext\leveltemplateid201916417\'01\u-3913 ?;}{\levelnumbers;}
\f3\fbias0\hres0\chhres0 \fi-360\li4680\lin4680 }{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\lvltentative\levelspace0\levelindent0{\leveltext\leveltemplateid201916419\'01o;}{\levelnumbers;}\f2\fbias0\hres0\chhres0 
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\rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid13453411 Note}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid15407465\charrsid13453411 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13388468\charrsid13453411 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15407465\charrsid13453411  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10516324\charrsid13453411 This form is designed for use with }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13453411 the following }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15806873 
Medicare Benefits Schedule (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13453411 MBS}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15806873 )}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid13453411 
 items. Users should be familiar with the most recent item definitions and requirements.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15407465\charrsid13453411 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid13388468\charrsid15407465 MBS }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15806873 item}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15806873\charrsid13453411  }{\rtlch\fcs1 
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\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\insrsid10447458 {\*\datafield 
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\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid10572654\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 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15407465 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3084351\charrsid13453411 This document is }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3084351\charrsid13453411 not}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3084351\charrsid13453411  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\insrsid12451973 M}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3084351\charrsid13453411 ental }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 H}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3084351\charrsid13453411 ealth }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid12451973 T}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3084351\charrsid13453411 reatment }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 P}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3084351\charrsid13453411 lan.}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3084351 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid6956213\charrsid15407465 Major headings are }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid6956213\charrsid15407465 bold; }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\i\f1\fs20\insrsid6956213\charrsid15407465 prompts to consider lower case. Response fields }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid6956213 can be e}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid6956213\charrsid15407465 xpand}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid6956213 ed}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid6956213\charrsid15407465  as required}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid6956213 . }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\ul\insrsid6956213\charrsid15407465 Underlined}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid6956213\charrsid15407465  items of either type are mandatory for compliance with Medicare requirements.}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid13453411 \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\tblrsid6956213\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw22 \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\insrsid15806873 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\tblrsid6956213\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw22 \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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1404161\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 
\insrsid1404161\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\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\pararsid1404161\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 
\insrsid1404161\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1404161\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 \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 \insrsid1404161\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\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\pararsid1404161\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 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid13388468  }{\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 \insrsid1404161\charrsid7933488 \trowd \irow6\irowband5\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\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\pararsid1404161\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\insrsid15806873 /}{\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 \insrsid1404161\charrsid7933488 
\trowd \irow7\irowband6\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc\clbrdrt
\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 
\clbrdrr\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow8\irowband7\ltrrow\ts15\trgaph128\trrh407\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth8207\clshdrawnil \cellx9952
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1404161\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\insrsid10447458 {\*\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\insrsid4796966  Female   }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid4796966\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\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\insrsid10447458 {\*\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\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 \irow8\irowband7\ltrrow\ts15\trgaph128\trrh407\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth8207\clshdrawnil \cellx9952\row \ltrrow
}\trowd \irow9\irowband8\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1404161\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976 Patient a}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976\charrsid7933488 ddress\cell }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6957976\charrsid2236790 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976\charrsid16059852 Patient}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976\charrsid16059852  }{\rtlch\fcs1 \ab\af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid6957976\charrsid16059852 phone}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976\charrsid16059852 Can leave message?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976 
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976\charrsid16059852  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid6957976\charrsid16059852  Yes    {\*\bkmkstart Check26}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1404161  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid6957976\charrsid16059852 {\*\bkmkend Check26} No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6957976\charrsid2236790 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1404161\charrsid2236790 \trowd \irow9\irowband8\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow10\irowband9\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1404161\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\insrsid15806873 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\insrsid7803740 Health}{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12145451  C}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid7803740 are Card/}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2058257 Pension}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12145451 er}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2058257  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12145451 Concession Card }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15806873 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 \insrsid1404161\charrsid6427833 
\trowd \irow10\irowband9\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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth1617\clshdrawnil \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3691\clshdrawnil \cellx5416\clvertalc
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth1945\clshdrawnil \cellx7401\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2491\clshdrawnil \cellx9952\row \ltrrow}\trowd \irow11\irowband10\lastrow \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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth1617 \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3691 \cellx5416\clvertalc\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3060 \cellx8516\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth1376 \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\pararsid1404161\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976\charrsid6427833 Emergency contact person details\cell \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976 Patient }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid6957976\charrsid6427833 consent for healthcare team to contact emergency }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976 contacts}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976\charrsid6427833 ?}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976\charrsid6427833 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10447458 {\*\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\insrsid6957976\charrsid6427833  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976 
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6957976\charrsid6427833  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid6957976\charrsid6427833  No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6957976\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 \insrsid4466554\charrsid6427833 \trowd \irow11\irowband10\lastrow \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\tblrsid1404161\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth1617 \cellx1685\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3691 \cellx5416\clvertalc\clbrdrt\brdrinset\brdrw15 
\clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3060 \cellx8516\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth1376 \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\brdrcf21 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw20 \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\cf19\insrsid11149811 Patient wellbeing assessment}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf19\insrsid13388468\charrsid13453411 \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\brdrcf21 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth10148\clcbpatraw20 \cellx10236\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\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\insrsid6956213\charrsid7340884 Reasons for presenting
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4741052\charrsid6956213 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid8276706\charrsid15817493 

\par }\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\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 \irow1\irowband0\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10228\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\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\tblrsid16533150\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6957976\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\insrsid6957976\charrsid6956213 Patient history}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid6957976 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6956213\charrsid13453411 Record:}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid12451973 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213 \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\ls13\adjustright\rin0\lin720\pararsid6956213\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 R}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid8276706 elevant medical/biological}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6956213  information}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid8276706 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 M}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid8276706 ental health/psychological}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213  information}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid8276706 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 S}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid8276706 ocial history}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13388468\charrsid6956213 \cell }\pard \ltrpar
\s19\ql \li720\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin720\pararsid6956213\yts15\contextualspace {\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\tblrsid16533150\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow3\irowband2\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\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\insrsid6957976\charrsid6956213 Results of mental state examination}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid4741052\charrsid13245083 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4593618 \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 \insrsid12201781\charrsid7933488 \trowd \irow3\irowband2\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh1082\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\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\insrsid8276706\charrsid6956213 Risk assessment 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 
Note any identified risks, including risks of self-harm and harm to others}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid8276706 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8276706\charrsid6957976 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid8276706\charrsid8276706 

\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706\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 \insrsid8276706\charrsid7933488 \trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh1082\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh527\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\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\insrsid8276706\charrsid6956213 Assessment/outcome tool used and results}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid8276706\charrsid6956213  
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6622611 (}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706\charrsid13453411 except where clinically inappropriate}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6622611 )}
{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid4741052\charrsid13453411 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706\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 \insrsid8276706\charrsid7933488 
\trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh527\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\trowd \irow6\irowband5\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\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\insrsid8276706\charrsid6956213 Provisional diagnosis of mental health disorder
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid4741052\charrsid14886295 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8276706\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 \insrsid8276706\charrsid7933488 
\trowd \irow6\irowband5\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\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\insrsid8276706\charrsid6956213 Case formulation}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid4741052\charrsid13245083 \cell }{
\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8276706 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8276706\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 \insrsid8276706\charrsid7933488 \trowd \irow7\irowband6\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8276706\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706\charrsid5574528 Setting }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10424082 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8276706\charrsid5574528 ersonal }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10424082 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706\charrsid5574528 ecovery }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid10424082 g}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8276706\charrsid5574528 oals}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10424082  \endash  considerations}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8276706 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213\charrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard\plain \ltrpar
\s19\ql \fi-360\li720\ri0\sa160\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls20\adjustright\rin0\lin720\pararsid6956213\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213\charrsid6956213 The patient themselves prioritising the goal/}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 s to focus on

\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213\charrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6956213\charrsid6956213 The CHIME framework: connectedness, hope, identity, meaning and purpose, and empowerment}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213\charrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6956213\charrsid6956213 Which strengths are relevant and can be built on to pursue goal/s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213\charrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6956213\charrsid6956213 How the person\rquote s values, treatment and support preferences will affect the action plan}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6956213 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213\charrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6956213\charrsid6956213 Breaking goals down into smaller, manageable steps and making plans for who will do what and when \endash  informally or using the SMART (specific, meaningful, attainable, realistic, t}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid6956213 imetabled) approach
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid6956213\charrsid6956213 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar
\s19\ql \fi-360\li720\ri0\sa160\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls20\adjustright\rin0\lin720\pararsid13245083\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6956213\charrsid6956213 Supporting the person to undertake independent or joint actions rather than accepting passive actions}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8276706\charrsid13245083 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa160\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6956213\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8276706\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 \insrsid8276706\charrsid7933488 
\trowd \irow8\irowband7\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\tblrsid6957976\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\cltxlrtb\clftsWidth3\clwWidth3222\clshdrawnil \cellx3290\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth6886\clshdrawnil \cellx10236\row 
}\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13388468 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10113716 \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\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth10289\clcbpatraw20 \cellx10377\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10113716\tscfirstrow\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf19\insrsid16461790 Personal recovery plan}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\cf19\insrsid10113716\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 \insrsid10113716\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\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth10289\clcbpatraw20 \cellx10377\row \ltrrow}\trowd \irow1\irowband0\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr
\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2243126\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1946\clshdrawnil \cellx2014\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx4253\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3220\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2804\clshdrawnil \cellx10377\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10113716\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid13388468 Identified issues/problems}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14886295 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid10113716 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid10113716\charrsid3699993 Goals
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3699993\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3699993\charrsid3699993 Record g}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14886295\charrsid3699993 oals made in collaboration with patient
\par }\pard\plain \ltrpar\s19\ql \li360\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin360\pararsid3699993\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid10113716 \cell }\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10113716\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\insrsid10113716\charrsid3699993 Treatments }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid16461790\charrsid3699993 and}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid10113716\charrsid3699993  interventions
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid14886295 \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\ls16\adjustright\rin0\lin720\pararsid14886295\yts15\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14886295 A}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid14886295 ctions and support services to achieve patient goals

\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid14886295\charrsid3699993 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid14886295\charrsid3699993 Actions to be taken by patient}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid14886295 
\par }\pard \ltrpar\s19\ql \li720\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin720\pararsid3699993\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid3699993\charrsid3699993 Consider:
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid16461790 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ltrpar
\s19\ql \fi-360\li720\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\ls16\adjustright\rin0\lin720\pararsid14886295\yts15\contextualspace {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid16461790 P}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12075979\charrsid14886295 sychological and/or pharmacological options}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14886295 
\par {\listtext\pard\plain\ltrpar \s19 \intbl\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f3\fs20\lang3081\langfe3081\langfenp3081\insrsid16461790 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16461790 F}{\rtlch\fcs1 
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\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid13388468 \cell }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid7803740 \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 \insrsid10113716\charrsid14447178 \trowd \irow2\irowband1\ltrrow\ts15\trgaph128\trrh1007\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\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2243126\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth1946\clshdrawnil \cellx2014\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2199\clshdrawnil \cellx4253\clvertalt
\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3220\clshdrawnil \cellx7513\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb
\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth2804\clshdrawnil \cellx10377\row \ltrrow}\trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 
\trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3080\clshdrawnil \cellx3148\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth7169\clshdrawnil \cellx10377
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10113716\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\insrsid10113716\charrsid3699993 Intervention/relapse prevention plan
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3699993\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716 
If appropriate at this stage, note arrangements to intervene in case of relapse or crisis}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4741052\charrsid3699993 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5775419\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid5775419 \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 \insrsid10113716\charrsid14447178 \trowd \irow3\irowband2\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3080\clshdrawnil \cellx3148\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth7169\clshdrawnil \cellx10377\row \ltrrow
}\trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10834777\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3080\clshdrawnil \cellx3148\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth7169\clshdrawnil \cellx10377
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5775419\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid10113716\charrsid5775419 Psycho-education}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid12871205  provided}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716 ?}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4741052\charrsid12871205 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8871440\yts15 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10113716\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid10113716 \tab \tab }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716  No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8871440 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid8871440\charrsid15817493  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\insrsid8871440 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10834777\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid10113716\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 \insrsid10113716\charrsid14447178 \trowd \irow4\irowband3\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb
\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10834777\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3080\clshdrawnil \cellx3148\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth7169\clshdrawnil \cellx10377\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10834777\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid12871205 Plan added to the patient\rquote s records?\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10113716\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716  Yes}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid10113716 \tab \tab }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid14970352  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716  No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\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 \insrsid10113716\charrsid14447178 \trowd \irow5\irowband4\ltrrow\ts15\trgaph128\trrh444\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 
\trbrdrv\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10834777\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth3080\clshdrawnil \cellx3148\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth7169\clshdrawnil \cellx10377\row \ltrrow
}\trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh363\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\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10834777\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth6340\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3909\clshdrawnil \cellx10377
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4741052\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid10113716\charrsid5775419 Completing the plan}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid4741052\delrsid3748279\charrsid15817493  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\ul\cf6\insrsid4741052\charrsid5775419 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10113716\yts15 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid5775419 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid214099 On completion of the plan, record (tick boxes below) that }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 you}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10113716\charrsid214099  ha}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 ve}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid214099 :
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 D}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid214099 iscussed the assessment with the patient
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 D}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\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\insrsid10113716\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid10113716\charrsid214099   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 O}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid214099 
ffered a copy of the plan to the patient and/or their carer (if agreed by patient)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\charrsid10113716 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10834777\yts15 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid214099 
Date plan completed}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\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 \insrsid10113716\charrsid14447178 \trowd \irow6\irowband5\ltrrow\ts15\trgaph128\trrh363\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\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10834777\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth6340\clshdrawnil \cellx6408\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3909\clshdrawnil \cellx10377\row \ltrrow
}\trowd \irow7\irowband6\lastrow \ltrrow\ts15\trgaph128\trrh922\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth6340\clshdrawnil \cellx6408\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3909\clshdrawnil \cellx10377
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpg\phmrg\posxc\posy364\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10113716\yts15 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10113716\charrsid10113716 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10113716\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 
\insrsid10113716\charrsid14447178 \trowd \irow7\irowband6\lastrow \ltrrow\ts15\trgaph128\trrh922\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv
\brdrinset\brdrw15 \tpvpg\tphmrg\tposxc\tposy364\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth10369\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3
\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 
\cltxlrtb\clftsWidth3\clwWidth6340\clshdrawnil \cellx6408\clvertalt\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 \cltxlrtb\clftsWidth3\clwWidth3909\clshdrawnil \cellx10377\row 
}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10113716 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12451973 \page 
\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\tblrsid5387866\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10319\clcbpatraw22 \cellx10407\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid12451973 Record of patient consent}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\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 \insrsid2966489\charrsid214099 
\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\tblrsid5387866\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15 \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10319\clcbpatraw22 \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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 I, ___________________________________________________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973\charrsid2632869 [}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid2632869 name of patient}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973\charrsid2632869 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489 
, agree to information about my}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  health being recorded in my medical file and being shared between the }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 GP}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  and other healthcare}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489  providers involved in my}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2966489\charrsid214099  care, as nominated above, to assist in the management of my healthcare. I understand that I must inform my GP if I wish to change the n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489 
ominated people involved in my care.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 
\par I understand that as part of my care under this Mental Health Treatment }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12451973 P}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 lan, I should attend }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489 the}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid151868 general practice}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid151868\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 for a review appointment at least }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7369033 four}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2966489\charrsid214099  weeks}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7369033 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7369033 
but no later than six}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  months}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid7369033 ,}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\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\insrsid151868 .}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\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 \insrsid2966489\charrsid14639418 \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\tblrsid14965788\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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2966489\charrsid214099 Name\cell }\pard \ltrpar
\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2966489\charrsid214099 Assessment\cell Treatment }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid8481367 p}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2966489\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 \insrsid2966489\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\tblrsid14965788\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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid2966489\charrsid214099 \cell }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid2966489\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 \insrsid2966489\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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8481367 W}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489 ith the following limitations:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid10097516 
 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489  }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid8481367 W}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489 ith the following limitations:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid10097516  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489\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 \insrsid2966489\charrsid214099 \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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489\charrsid214099  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8481367 W}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 ith the following limitations:\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid10447458 {\*\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\insrsid2966489\charrsid214099 \cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2966489\charrsid214099  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489\charrsid214099  }{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid8481367 W}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 ith the following limitations:\cell }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 
 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid2966489\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 \insrsid2966489\charrsid214099 
\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\tblrsid14965788\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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid16535067 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid8481367 __________________________________________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid2632869 Signature of patient or guardian\cell }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid16535067 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid8481367 ________/________/________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid2632869 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 \insrsid2966489\charrsid214099 \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\tblrsid14965788\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\tblrsid14965788\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\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 I, ____________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid2966489 ___________________________}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 _, have discussed the plan and referral}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8481367 /}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid214099 s with the patient.
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\tx2210\tx7160\tx12263\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid2632869 Full name of GP}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid16535067 \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 \insrsid2966489\charrsid214099 \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\tblrsid14965788\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\tblrsid14965788\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\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid5834537 
\par }\pard \ltrpar\qr \li0\ri0\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11206973\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4679164\charrsid5834537 Mental Health Treatment Plan }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8481367 i}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4679164\charrsid5834537 ncluded:                                                          }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\caps\f1\fs20\insrsid4679164\charrsid5834537 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14251754\charrsid5834537 
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16068316\charrsid5834537 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid5834537 __________________________________________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid2632869 Signature of GP}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid2966489\charrsid16535067 \cell }\pard \ltrpar
\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid5834537 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14251754\charrsid5834537 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16608795\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537      }{\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16608795\charrsid5834537 No}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537          }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16608795\charrsid5834537 Yes (if yes, please select below)
\par }\pard \ltrpar\ql \li0\ri0\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16608795\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid16608795\charrsid5834537                         MBS }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8481367 i}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16608795\charrsid5834537 tem }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8481367 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid16608795\charrsid5834537 umber}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid16608795\charrsid5834537 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537   
\par                         }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid16608795\charrsid5834537 2700    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid16608795\charrsid5834537 2701    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid16608795\charrsid5834537 2715  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid16608795\charrsid5834537 2717 }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537  }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16068316\charrsid5834537 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16608795\charrsid5834537   }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14251754\charrsid5834537 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14965788\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid5834537 ________/________/________
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid2966489\charrsid2632869 Date}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid2966489\charrsid16535067 \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 \insrsid2966489\charrsid12979906 
\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\tblrsid14965788\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5065\clshdrawnil \cellx5133\clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrinset\brdrw15 \clbrdrr
\brdrinset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth5214\clshdrawnil \cellx10407\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13440585 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15882468 
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4862071 \page 
\par \ltrrow}\trowd \irow0\irowband-1\lastrow \ltrrow\ts27\trgaph128\trrh360\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposy1170\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3
\trpaddfb3\trpaddfr3\tblrsid3818344\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw20 \cellx9952\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\pvpg\phmrg\posy1170\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3818344\tscfirstrow\yts27 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf19\insrsid8481367\charrsid2632869 Re}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf19\insrsid8481367 quest for services}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\cf19\insrsid3818344\charrsid2632869 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\cf8\insrsid3818344\charrsid8725552 \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 \insrsid3818344\charrsid8725552 \trowd \irow0\irowband-1\lastrow \ltrrow\ts27\trgaph128\trrh360\trleft8\trkeep\trbrdrt\brdrinset\brdrw15 \trbrdrl
\brdrinset\brdrw15 \trbrdrb\brdrinset\brdrw15 \trbrdrr\brdrinset\brdrw15 \trbrdrh\brdrinset\brdrw15 \trbrdrv\brdrinset\brdrw15 
\tpvpg\tphmrg\tposy1170\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9944\trftsWidthB3\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3
\trpaddfb3\trpaddfr3\tblrsid3818344\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrinset\brdrw15 \clbrdrl\brdrinset\brdrw15 \clbrdrb\brdrinset\brdrw15 \clbrdrr\brdrinset\brdrw15\brdrcf21 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth9864\clcbpatraw20 \cellx9952\row }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8725552 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8725552\charrsid8725552 
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts28\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\tblrsid7369033\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\pararsid8725552\yts28 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \b\f1\fs20\insrsid8725552\charrsid8725552 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8725552\yts28 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552 Date: }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang3081\langfe2052\langfenp2052\insrsid8725552\charrsid8725552 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid8725552\charrsid8725552 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 To}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid151868 :}{\rtlch\fcs1 \af1\afs20 
\ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067\charrsid8725552 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 [A}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067 ttn}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067\charrsid8725552 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067 Address}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067\charrsid8725552 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067 Post code}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 ]
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 
\par Subject:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid8725552\charrsid8725552 \hich\af1\dbch\af31505\loch\f1  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid8725552\charrsid8725552 \hich\af1\dbch\af31505\loch\f1 L}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 etter}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid8725552\charrsid8725552 
\hich\af1\dbch\af31505\loch\f1  of }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid16535067 \hich\af1\dbch\af31505\loch\f1 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid8725552\charrsid8725552 \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\insrsid16535067 \hich\af1\dbch\af31505\loch\f1 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2052\loch\af1\hich\af1\dbch\af31505\langnp2057\langfenp2052\insrsid8725552\charrsid8725552 \hich\af1\dbch\af31505\loch\f1 ervices
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 
\par 
\par }\pard \ltrpar\qj \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8725552\yts28 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552 Dear Dr
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8725552\yts28 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid8725552\charrsid8725552 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552 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\insrsid8725552\charrsid8725552  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid8725552\charrsid8725552 Yes  }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid8725552\charrsid8725552  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\insrsid8725552\charrsid8725552 No
\par 
\par Specific treatment requests}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid151868 :}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552  [  ]
\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\insrsid8725552 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16535067\charrsid8725552 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552 Looking forward to your reply}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid151868 .}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552 

\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 Yours sincerely,
\par 
\par 
\par 
\par [Signature]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 \tab \tab \tab \tab 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 [Physician\rquote }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 s }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid16535067 n}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 ame}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid2632869  and title}{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\expnd0\expndtw-1\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 ]}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langnp2057\langfenp1033\insrsid8725552\charrsid8725552 
\par 
\par \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8725552\charrsid8725552 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\caps\f1\fs20\insrsid16535067 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \caps\f1\fs20\insrsid16535067\charrsid12798788 [}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16535067\charrsid12798788 Provider number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid8725552\charrsid12798788 ]
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8725552\yts28 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8725552\charrsid8725552 
\par 
\par 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8725552\yts28 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8725552\charrsid8725552 
\par }\pard \ltrpar\qc \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8725552\yts28 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8725552\charrsid8725552 
\par 
\par 
\par 
\par }\pard \ltrpar\ql \li0\ri0\sb120\sa120\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3675005\yts28 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8725552\charrsid8725552 \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 
\insrsid8725552\charrsid8725552 \trowd \irow0\irowband0\lastrow \ltrrow\ts28\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\tblrsid7369033\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\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2966489 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts23\trgaph108\trrh363\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth10268\clcbpatraw20 \cellx10519\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\cf19\insrsid4213569\charrsid7803740 R}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf19\insrsid16535067 eview}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\cf19\insrsid4213569\charrsid7803740 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4213569 
\trowd \irow0\irowband0\ltrrow\ts23\trgaph108\trrh363\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10113716\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \clcbpat20\cltxlrtb\clftsWidth3\clwWidth10268\clcbpatraw20 \cellx10519\row \ltrrow
}\trowd \irow1\irowband1\ltrrow\ts23\trgaph108\trrh287\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13385234\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10268\clshdrawnil \cellx10519\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13385234\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14249401\charrsid7803740 MBS }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16535067 item number}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401\charrsid7803740 :}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid14249401\charrsid7803740    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401\charrsid7803740  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\charrsid7803740  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14249401\charrsid7803740 2712    }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14249401\charrsid7803740  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid10447458 {\*\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\charrsid7803740  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\caps\f1\fs20\insrsid14249401\charrsid7803740 2719}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14249401\charrsid7803740 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14249401 \trowd \irow1\irowband1\ltrrow
\ts23\trgaph108\trrh287\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13385234\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth10268\clshdrawnil \cellx10519\row \ltrrow}\trowd \irow2\irowband2\ltrrow
\ts23\trgaph108\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4466554\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\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\insrsid4466554\charrsid5775419 D}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid4213569\charrsid5775419 ate for review with GP
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4213569\charrsid7803740 (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16535067 I}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4213569\charrsid7803740 nitial review }{\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16535067 four}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4213569\charrsid7803740  weeks to }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16535067 six}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid4213569\charrsid7803740  months after completion of plan)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4741052 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3086319\charrsid7803740 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts23 {\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\cf6\insrsid4213569 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4741052\charrsid7803740 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 
\ltrch\fcs0 \fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4213569 \trowd \irow2\irowband2\ltrrow\ts23\trgaph108\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 
\trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4466554\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts23\trgaph108\trrh359\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl
\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4466554\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4466554\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\charrsid5775419 As}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid13064246\charrsid5775419 sessment}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid15943092\charrsid5775419 /outcome}{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid13064246\charrsid5775419  tool results}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13064246  on review}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3086319  }{\rtlch\fcs1 
\ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid6622611\charrsid328580 (}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3086319\charrsid328580 except where clinically inappropriate}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid6622611\charrsid328580 )}{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid4741052\charrsid5775419 
\par }{\rtlch\fcs1 \ab\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3086319\charrsid7803740 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4213569\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid4741052\charrsid7803740 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 
\fs24\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4213569 \trowd \irow3\irowband3\ltrrow\ts23\trgaph108\trrh359\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 
\trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4466554\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts23\trgaph108\trrh366\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl
\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13385234\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8871440\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8871440\charrsid9572134 Comments}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8871440  \endash  }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid16535067\charrsid328580 r}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\ul\insrsid8871440\charrsid328580 eview of patient\rquote s progress against goals, checking, reinforcing and expanding education, modification of treatment plan (if required)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid8871440\charrsid9572134 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13385234\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid9315371 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14027631 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14027631\charrsid9315371 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5775419\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid4213569\charrsid5775419 \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\trrh366\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb\brdroutset\brdrw15 
\trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13385234\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13385234\yts23 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang3081\langfe3081\cgrid\langnp3081\langfenp3081 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\ul\insrsid14027631\charrsid5775419 Plan for crisis intervention and/or for relapse prevention}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14027631\charrsid8871440 , }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f1\fs20\insrsid14027631\charrsid328580 if appropriate and if not previously provided}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14027631\charrsid8871440 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14027631 
\par 
\par 
\par 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid14027631\charrsid7803740 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5775419\yts23 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\b\f1\fs20\insrsid14027631\charrsid5775419 \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 \insrsid14027631 \trowd \irow5\irowband5\lastrow \ltrrow\ts23\trgaph108\trrh366\trleft171\trbrdrt\brdroutset\brdrw15 \trbrdrl\brdroutset\brdrw15 \trbrdrb
\brdroutset\brdrw15 \trbrdrr\brdroutset\brdrw15 \trbrdrh\brdroutset\brdrw15 \trbrdrv\brdroutset\brdrw15 
\trftsWidth3\trwWidth10348\trftsWidthB3\trautofit1\trspdl20\trspdt20\trspdb20\trspdr20\trspdfl3\trspdft3\trspdfb3\trspdfr3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13385234\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind163\tblindtype3 \clvertalc\clbrdrt\brdroutset\brdrw15 \clbrdrl\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth4193\clshdrawnil \cellx4424\clvertalt\clbrdrt\brdroutset\brdrw15 \clbrdrl
\brdroutset\brdrw15 \clbrdrb\brdroutset\brdrw15 \clbrdrr\brdroutset\brdrw15 \cltxlrtb\clftsWidth3\clwWidth6035\clshdrawnil \cellx10519\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid9663107 
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid214099\charrsid12871205 
\par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a
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