Provider’s Name (Licensure):____________________________________________________________________________________ Address:______________________________________________________________________State:____________ZIP___________ Telephone #:____________________________Fax #:____________________________Tax ID #:____________________________ Date Provider Wishes Authorization to Start:_____________________Diagnosis:__________________________________________ Number of visits requested:_______________________ RISK ASSESSMENT/PATIENT CLINICAL INFORMATION
SUICIDE: ___________ Not Present___________ Ideation____________ Plan____________ Means____________ Prior Attempt No Harm Contract: _________Yes _________No Date of Last Ideation/attempt:_______________________________ HOMICIDE: __________ Not Present__________ Ideation____________ Plan____________ Means____________ Prior Attempt No Harm Contract: _________Yes _________No Date of Last Ideation/attempt:_______________________________ Mood Disturbances: _____ Depression_____ Mania_____ Hypomania_____ Anxiety Onset:________________________ Behavioral Disturbances: ______Recklessness_____ Impulsiveness______ Decline in functioning Onset:_______________ Eating Disorder Onset:______________________________ Dementia Onset:___________________________________________ Substance Abuse Onset:___________ Other (please give brief description):____________________________________________ Hallucinations: _______________ Auditory_______________ Visual______________ Command Onset:_______________
_______________ Delusions ______________ Paranoia Onset:_______________
H1N1 Flu (Swine Flu) General Information The Facts Swine influenza, also called “swine flu,” is a contagious respiratory disease that affects pigs. Just like humans, pigs can get the flu. The swine flu can be passed from pig to pig by direct contact, indirect contact (e.g., a pig coming in contact with a surface that has the virus), or through tiny particles in the air. Strain
TREATMENT PLAN