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/contrib/forms/assessment_intake/view.php

https://github.com/md-tech/openemr
PHP | 303 lines | 300 code | 3 blank | 0 comment | 0 complexity | 918a12660a10823e80dc39fd6eb30832 MD5 | raw file
    

  1. <!-- Forms generated from formsWiz -->
    2. 

  2. <?php
    3. 

  3. include_once("../../globals.php");
    4. 

  4. ?>
    5. 

  5. <html><head>
    6. 

  6. <?php html_header_show();?>
    7. 

  7. <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
    8. 

  8. </head>
    9. 

  9. <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
    10. 

  10. <?php
    11. 

  11. include_once("$srcdir/api.inc");
    12. 

  12. 

  13. $obj = formFetch("form_assessment_intake", $_GET["id"]);
    14. 

  14. 

  15. ?>
    16. 

  16. <form method=post action="<?echo $rootdir?>/forms/assessment_intake/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
    17. 

  17. <span class="title"><center><b>Assessment and Intake</b></center></span><br><br>
    18. 

  18. 

  19. <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
    20. 

  20. <br>
    21. 

  21. <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
    22. 

  22.  onclick="top.restoreSession()">[Don't Save Changes]</a>
    23. 

  23. <br></br>
    24. 

  24. 

  25. <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
    26. 

  26. $result = SqlFetchArray($res); ?>
    27. 

  27. <b>Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?> 
    28. 

  28. <img src="../../../images/space.gif" width="572" height="1">
    29. 

  29. <b>Date:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
    30. 

  30. <b>SSN:</b>&nbsp;<?php echo $result['ss'];?><img src="../../../images/space.gif" width="172" height="1">
    31. 

  31. <b>DCN:</b>&nbsp;<input type="entry" name="dcn" value="<?php echo stripslashes($obj{"dcn"});?>"><img src="../../../images/space.gif" width="125" height="1">
    32. 

  32. <label><b>Location:</b>&nbsp;<input type="entry" name="location" value="<?php echo stripslashes($obj{"location"});?>"></label><br><br>
    33. 

  33. <b>Address:</b>&nbsp; <?php echo $result['street'] . ',&nbsp' . $result['city']  . ',&nbsp' . $result['state'] . '&nbsp;' . $result['postal_code'];?><br><br>
    34. 

  34. <b>Telephone Number:</b>&nbsp; <?php echo $result['phone_home'];?><img src="../../../images/space.gif" width="400" height="1"> 
    35. 

  35. <b>Date of Birth:</b>&nbsp;<?php echo $result['DOB'];?><br><br>
    36. 

  36. <label><b>Time In:</b>&nbsp;<input type="entry" name="time_in" value="<?php echo stripslashes($obj{"time_in"});?>"></label><img src="../../../images/space.gif" width="65" height="1">
    37. 

  37. <label><b>Time Out:</b>&nbsp;<input type="entry" name="time_out" value="<?php echo stripslashes($obj{"time_out"});?>"></label><img src="../../../images/space.gif" width="65" height="1">
    38. 

  38. <label><b>Referral Source:</b>&nbsp;<input type="entry" name="referral_source" value="<?php echo stripslashes($obj{"referral_source"});?>"></label><br><br>
    39. 

  39. <b>Purpose:</b>&nbsp; <input type=checkbox name='new_client_eval' <?php if ($obj{"new_client_eval"} == "on") {echo "checked";};?>  ><b>New client evaluation</b><img src="../../../images/space.gif" width="10" height="1">
    40. 

  40. <input type=checkbox name='readmission' <?php if ($obj{"readmission"} == "on") {echo "checked";};?>  ><b>Readmission</b><img src="../../../images/space.gif" width="35" height="1">
    41. 

  41. <input type=checkbox name='consultation' <?php if ($obj{"consultation"} == "on") {echo "checked";};?> ><b>Consultation</b><br><br> 
    42. 

  42. <label><b>Copy sent to:</b>&nbsp;<input type="entry" name="copy_sent_to" value="<?echo stripslashes($obj{"copy_sent_to"});?>"></label><br><br>
    43. 

  43. <b>Why is Assessment being requested (Goals and treatment expectations of the individual requesting services):</b><br>
    44. 

  44. <textarea cols=100 rows=3 name="reason_why" ><?php echo stripslashes($obj{"reason_why"});?></textarea><br>
    45. 

  45. <b>Behavior that led to Assessment:</b><br>
    46. 

  46. <textarea cols=100 rows=5 wrap=virtual name="behavior_led_to" ><?php echo stripslashes($obj{"behavior_led_to"});?></textarea><br><br>
    47. 

  47. <b><u></u>Areas of Functioning:</b><br><br>
    48. 

  48. <b>School/Work:</b><br>
    49. 

  49. <textarea cols=100 rows=3 wrap=virtual name="school_work" ><?php echo stripslashes($obj{"school_work"});?></textarea><br><br>
    50. 

  50. <b>Personal Relationships (Intimate):</b>&nbsp;
    51. 

  51. <textarea cols=100 rows=4 wrap=virtual name="personal_relationships" ><?php echo stripslashes($obj{"personal_relationships"});?></textarea><br><br>
    52. 

  52. <b>Family Relationships:</b>&nbsp; &nbsp;
    53. 

  53. <input type=checkbox name='fatherc' <?php if ($obj{"fatherc"} == "on") {echo "checked";};?>  >&nbsp;<b>Father involved/present/absent (Describe relationship)</b><br>
    54. 

  54. <textarea cols=100 rows=3 wrap=virtual name="father_involved" ><?php echo stripslashes($obj{"father_involved"});?></textarea><br>
    55. 

  55. <input type=checkbox name='motherc' <?php if ($obj{"motherc"} == "on") {echo "checked";};?>  >&nbsp;<b>Mother involved/present/absent (Describe relationship)</b><br>
    56. 

  56. <textarea cols=100 rows=3 wrap=virtual name="mother_involved" ><?php echo stripslashes($obj{"mother_involved"});?></textarea><br><br>
    57. 

  57. <b>Number of children:</b>&nbsp;<input type="entry" name="number_children"value="<?php echo stripslashes($obj{"number_children"});?>"><br><b>Names, ages, quality of relationship(s):</b><br>
    58. 

  58. <textarea cols=100 rows=3 wrap=virtual name="siblings" ><?php echo stripslashes($obj{"siblings"});?></textarea><br><br>
    59. 

  59. <b>Other family relationships:</b><br>
    60. 

  60. <textarea cols=100 rows=2 wrap=virtual name="other_relationships" ><?php echo stripslashes($obj{"other_relationships"});?></textarea><br><br>
    61. 

  61. <b>Social Relationships (Peers/Friends):</b><br>
    62. 

  62. <textarea cols=100 rows=3 wrap=virtual name="social_relationships" ><?php echo stripslashes($obj{"social_relationships"});?></textarea><br><br>
    63. 

  63. <b>Psychological/Personal Functioning (Current symptons):</b><br>
    64. 

  64. <textarea cols=100 rows=3 wrap=virtual name="current_symptoms" ><?php echo stripslashes($obj{"current_symptoms"});?></textarea><br><br>
    65. 

  65. <b>Personal resources and strengths (including the availability & use of family and peers):</b><br>
    66. 

  66. <textarea cols=100 rows=3 wrap=virtual name="personal_strengths" ><?php echo stripslashes($obj{"personal_strengths"});?></textarea><br><br>
    67. 

  67. <b>Spiritual:</b>&nbsp;<input type="entry" name="spiritual" value="<?echo stripslashes($obj{"spiritual"});?>">&nbsp;<img src="../../../images/space.gif" width="35" height="1">
    68. 

  68. <b>Legal:</b>&nbsp;<input type="entry" name="legal" value="<?echo stripslashes($obj{"legal"});?>"><br><br>
    69. 

  69. <b>Prior Mental Health History/Treatment:</b><br>
    70. 

  70. <textarea cols=100 rows=3 wrap=virtual name="prior_history" ><?php echo stripslashes($obj{"prior_history"});?></textarea><br><br>
    71. 

  71. <b>Number of admissions:</b>&nbsp;<input type="entry" name="number_admitt" value="<?echo stripslashes($obj{"number_admitt"});?>">&nbsp;<img src="../../../images/space.gif" width="35" height="1">
    72. 

  72. <b>Types of admissions:</b>&nbsp;<input type="entry" name="type_admitt" value="<?echo stripslashes($obj{"type_admitt"});?>"><br><br>
    73. 

  73. <b>Alcohol and substance use for the past 30 days:</b><br>
    74. 

  74. <textarea cols=100 rows=3 wrap=virtual name="substance_use" ><?php echo stripslashes($obj{"substance_use"});?></textarea><br><br>
    75. 

  75. <b>Substance abuse history (Include duration, patterns, and consequences of use):</b><br>
    76. 

  76. <textarea cols=100 rows=3 wrap=virtual name="substance_abuse" ><?php echo stripslashes($obj{"substance_abuse"});?></textarea><br><br>
    77. 

  77. <b><u>Diagnoses</u></b><br><br>
    78. 

  78. <b>Axis I:</b><br>
    79. 

  79. <textarea cols=100 rows=3 wrap=virtual name="axis1" ><?php echo stripslashes($obj{"axis1"});?></textarea><br><br>
    80. 

  80. <b>Axis II:</b><br>
    81. 

  81. <textarea cols=100 rows=3 wrap=virtual name="axis2" ><?php echo stripslashes($obj{"axis2"});?></textarea><br><br>
    82. 

  82. <b>Axis III:</b><br>
    83. 

  83. <textarea cols=100 rows=3 wrap=virtual name="axis3" ><?php echo stripslashes($obj{"axis3"});?></textarea><br><br>
    84. 

  84. <b><u>Allergies/Adverse reactions to medications:</u></b>&nbsp;<input type="entry" name="allergies" value="<?echo stripslashes($obj{"allergies"});?>"><br><br>
    85. 

  85. <b>Axis IV Psychosocial and environmental problems in the last year:</b><br>
    86. 

  86. <input type=checkbox name='ax4_prob_support_group' <?php if ($obj{"ax4_prob_support_group"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems with primary support group</b>
    87. 

  87. <img src="../../../images/space.gif" width="35" height="1">
    88. 

  88. <input type=checkbox name='ax4_prob_soc_env' <?php if ($obj{"ax4_prob_soc_env"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems related to the social environment</b><br>
    89. 

  89. 

  90. <input type=checkbox name='ax4_educational_prob' <?php if ($obj{"ax4_educational_prob"} == "on") {echo "checked";};?>  >&nbsp;<b>Educational problems</b>
    91. 

  91. <img src="../../../images/space.gif" width="5" height="1">
    92. 

  92. <input type=checkbox name='ax4_occ_prob' <?php if ($obj{"ax4_occ_prob"} == "on") {echo "checked";};?>  >&nbsp;<b>Occupational problems</b>
    93. 

  93. <img src="../../../images/space.gif" width="5" height="1">
    94. 

  94. <input type=checkbox name='ax4_housing' <?php if ($obj{"ax4_housing"} == "on") {echo "checked";};?>  >&nbsp;<b>Housing problems</b>
    95. 

  95. <img src="../../../images/space.gif" width="5" height="1">
    96. 

  96. <input type=checkbox name='ax4_economic' <?php if ($obj{"ax4_economic"} == "on") {echo "checked";};?>  >&nbsp;<b>Economic problems</b><br>
    97. 

  97. <input type=checkbox name='ax4_access_hc' <?php if ($obj{"ax4_access_hc"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems with access to health care services</b>
    98. 

  98. <img src="../../../images/space.gif" width="5" height="1">
    99. 

  99. <input type=checkbox name='ax4_legal' <?php if ($obj{"ax4_legal"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems related to interaction with the legal system/crime</b><br>
    100. 

  100. <input type=checkbox name='ax4_other_cb' <?php if ($obj{"ax4_other_cb"} == "on") {echo "checked";};?>  >&nbsp;<b>Other (specify):</b><br>
    101. 

  101. <textarea cols=100 rows=2 wrap=virtual name="ax4_other" ><?php echo stripslashes($obj{"ax4_other"});?></textarea><br><br>
    102. 

  102. <b>Axis V Global Assessment of Functioning (GAF) Scale (100 down to 0):</b>
    103. 

  103. <img src="../../../images/space.gif" width="5" height="1"><br>
    104. 

  104. <b>Currently</b><input type="entry" name="ax5_current" value="<?echo stripslashes($obj{"ax5_current"});?>">
    105. 

  105. <img src="../../../images/space.gif" width="5" height="1">
    106. 

  106. <b>Past Year</b><input type="entry" name="ax5_past" value="<?echo stripslashes($obj{"ax5_current"});?>"><br><br>
    107. 

  107. <b><u>Assessment of Currently Known Risk Factors:</u></b><br><br>
    108. 

  108. <b>Suicide:</b><br><input type=checkbox name='risk_suicide_na' <?php if ($obj{"risk_suicide_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
    109. 

  109. 	<img src="../../../images/space.gif" width="5" height="1">
    110. 

  110. 	<b>Behaviors:</b>&nbsp;
    111. 

  111. 	<img src="../../../images/space.gif" width="5" height="1">
    112. 

  112. 	<input type=checkbox name='risk_suicide_nk' <?php if ($obj{"risk_suicide_nk"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Known</b>
    113. 

  113. 	<img src="../../../images/space.gif" width="5" height="1">
    114. 

  114. 	<input type=checkbox name='risk_suicide_io' <?php if ($obj{"risk_suicide_io"} == "on") {echo "checked";};?>  >&nbsp;<b>Ideation only</b>
    115. 

  115. 	<img src="../../../images/space.gif" width="5" height="1">
    116. 

  116. 	<input type=checkbox name='risk_suicide_plan' <?php if ($obj{"risk_suicide_plan"} == "on") {echo "checked";};?>  >&nbsp;<b>Plan</b><br>
    117. 

  117. 	<img src="../../../images/space.gif" width="100" height="1">
    118. 

  118. 	<input type=checkbox name='risk_suicide_iwom' <?php if ($obj{"risk_suicide_iwom"} == "on") {echo "checked";};?>  >&nbsp;<b>Intent without means</b>
    119. 

  119. 	<img src="../../../images/space.gif" width="5" height="1">
    120. 

  120. 	<input type=checkbox name='risk_suicide_iwm' <?php if ($obj{"risk_suicide_iwm"} == "on") {echo "checked";};?>  >&nbsp;<b>Intent with means</b><br>
    121. 

  121. <br>
    122. 

  122. <b>Homocide:</b><br><input type=checkbox name='risk_homocide_na' <?php if ($obj{"risk_homocide_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
    123. 

  123. 	<img src="../../../images/space.gif" width="5" height="1">
    124. 

  124. 	<b>Behaviors:</b>
    125. 

  125. 	<img src="../../../images/space.gif" width="5" height="1">
    126. 

  126. 	<input type=checkbox name='risk_homocide_nk' <?php if ($obj{"risk_homocide_nk"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Known</b>
    127. 

  127. 	<img src="../../../images/space.gif" width="5" height="1">
    128. 

  128. 	<input type=checkbox name='risk_homocide_io' <?php if ($obj{"risk_homocide_io"} == "on") {echo "checked";};?>  >&nbsp;<b>Ideation only</b>
    129. 

  129. 	<img src="../../../images/space.gif" width="5" height="1">
    130. 

  130. 	<input type=checkbox name='risk_homocide_plan' <?php if ($obj{"risk_homocide_plan"} == "on") {echo "checked";};?>  >&nbsp;<b>Plan</b><br>
    131. 

  131. 	<img src="../../../images/space.gif" width="100" height="1">
    132. 

  132. 	<input type=checkbox name='risk_homocide_iwom' <?php if ($obj{"risk_homocide_iwom"} == "on") {echo "checked";};?>  >&nbsp;<b>Intent without means</b>
    133. 

  133. 	<img src="../../../images/space.gif" width="5" height="1">
    134. 

  134. 	<input type=checkbox name='risk_homocide_iwm' <?php if ($obj{"risk_homocide_iwm"} == "on") {echo "checked";};?>  >&nbsp;<b>Intent with means</b><br>
    135. 

  135. <br>	
    136. 

  136. <b>Compliance with treatment:</b><br><input type=checkbox name='risk_compliance_na' <?php if ($obj{"risk_compliance_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
    137. 

  137. 	<img src="../../../images/space.gif" width="5" height="1">
    138. 

  138. 	<input type=checkbox name='risk_compliance_fc' <?php if ($obj{"risk_compliance_fc"} == "on") {echo "checked";};?>  >&nbsp;<b>Full compliance</b>
    139. 

  139. 	<img src="../../../images/space.gif" width="5" height="1">
    140. 

  140. 	<input type=checkbox name='risk_compliance_mc' <?php if ($obj{"risk_compliance_mc"} == "on") {echo "checked";};?>  >&nbsp;<b>Minimal compliance</b>
    141. 

  141. 	<img src="../../../images/space.gif" width="5" height="1">
    142. 

  142. 	<input type=checkbox name='risk_compliance_moc' <?php if ($obj{"risk_compliance_moc"} == "on") {echo "checked";};?>  >&nbsp;<b>Moderate compliance</b><br>
    143. 

  143. 	<img src="../../../images/space.gif" width="100" height="1">
    144. 

  144. 	<input type=checkbox name='risk_compliance_var' <?php if ($obj{"risk_compliance_var"} == "on") {echo "checked";};?>  >&nbsp;<b>Variable</b>
    145. 

  145. 	<img src="../../../images/space.gif" width="5" height="1">
    146. 

  146. 	<input type=checkbox name='risk_compliance_no' <?php if ($obj{"risk_compliance_no"} == "on") {echo "checked";};?>  >&nbsp;<b>Little or no compliance</b><br>
    147. 

  147. <br>	
    148. 

  148. <b>Substance Abuse:</b><br><input type=checkbox name='risk_substance_na' <?php if ($obj{"risk_substance_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
    149. 

  149. 	<img src="../../../images/space.gif" width="5" height="1">
    150. 

  150. 	<input type=checkbox name='risk_substance_none' <?php if ($obj{"risk_substance_none"} == "on") {echo "checked";};?>  >&nbsp;<b>None/normal use:</b><br>
    151. 

  151.     <textarea cols=100 rows=1 wrap=virtual name="risk_normal_use" ><?php echo stripslashes($obj{"risk_normal_use"});?></textarea><br>
    152. 

  152. 	<input type=checkbox name='risk_substance_ou' <?php if ($obj{"risk_substance_ou"} == "on") {echo "checked";};?>  >&nbsp;<b>Overuse</b>
    153. 

  153. 	<img src="../../../images/space.gif" width="5" height="1">
    154. 

  154. 	<input type=checkbox name='risk_substance_dp' <?php if ($obj{"risk_substance_dp"} == "on") {echo "checked";};?>  >&nbsp;<b>Dependence</b>
    155. 

  155. 	<img src="../../../images/space.gif" width="5" height="1">
    156. 

  156. 	<input type=checkbox name='risk_substance_ur' <?php if ($obj{"risk_substance_ur"} == "on") {echo "checked";};?>  >&nbsp;<b>Unstable remission of abuse</b>
    157. 

  157. 	<img src="../../../images/space.gif" width="5" height="1">
    158. 

  158. 	<input type=checkbox name='risk_substance_ab' <?php if ($obj{"risk_substance_ab"} == "on") {echo "checked";};?>  >&nbsp;<b>Abuse</b><br>
    159. 

  159. <br>	
    160. 

  160. <b>Current physical or sexual abuse:</b><br><input type=checkbox name='risk_sexual_na' <?php if ($obj{"risk_sexual_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
    161. 

  161. 	<img src="../../../images/space.gif" width="5" height="1">
    162. 

  162. 	<input type=checkbox name='risk_sexual_y' <?php if ($obj{"risk_sexual_y"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
    163. 

  163. 	<img src="../../../images/space.gif" width="5" height="1">
    164. 

  164. 	<input type=checkbox name='risk_sexual_n' <?php if ($obj{"risk_sexual_n"} == "on") {echo "checked";};?>>&nbsp;<b>No</b><br>
    165. 

  165. 	<b>Legally reportable?</b>&nbsp;<input type=checkbox name='risk_sexual_ry' <?php if ($obj{"risk_sexual_ry"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
    166. 

  166.    	<img src="../../../images/space.gif" width="5" height="1">
    167. 

  167. 	<input type=checkbox name='risk_sexual_rn' <?php if ($obj{"risk_sexual_rn"} == "on") {echo "checked";};?>>&nbsp;<b>No</b>
    168. 

  168. 	<img src="../../../images/space.gif" width="5" height="1">
    169. 

  169. 	<b>If yes, client is </b>&nbsp;<input type=checkbox name='risk_sexual_cv' <?php if ($obj{"risk_sexual_cv"} == "on") {echo "checked";};?>>&nbsp;<b>victum</b>
    170. 

  170. 	&nbsp;<input type=checkbox name='risk_sexual_cp' <?php if ($obj{"risk_sexual_cp"} == "on") {echo "checked";};?>>&nbsp;<b>perpetrator</b><br>
    171. 

  171. 	<input type=checkbox name='risk_sexual_b' <?php if ($obj{"risk_sexual_b"} == "on") {echo "checked";};?>>&nbsp;<b>Both</b>&nbsp;
    172. 

  172. 	<img src="../../../images/space.gif" width="5" height="1">
    173. 

  173. 	<input type=checkbox name='risk_sexual_nf' <?php if ($obj{"risk_sexual_nf"} == "on") {echo "checked";};?>>&nbsp;<b>neither, but abuse exists in family</b>&nbsp;<br>
    174. 

  174. <br>
    175. 

  175. <b>Current child/elder abuse:</b><br><input type=checkbox name='risk_neglect_na' <?php if ($obj{"risk_neglect_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
    176. 

  176. 	<img src="../../../images/space.gif" width="5" height="1">
    177. 

  177. 	<input type=checkbox name='risk_neglect_y' <?php if ($obj{"risk_neglect_y"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
    178. 

  178. 	<img src="../../../images/space.gif" width="5" height="1">
    179. 

  179. 	<input type=checkbox name='risk_neglect_n' <?php if ($obj{"risk_neglect_n"} == "on") {echo "checked";};?>>&nbsp;<b>No</b><br>
    180. 

  180. 	<b>Legally reportable?</b>&nbsp;<input type=checkbox name='risk_neglect_ry' <?php if ($obj{"risk_neglect_ry"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
    181. 

  181.    	<img src="../../../images/space.gif" width="5" height="1">
    182. 

  182. 	<input type=checkbox name='risk_neglect_rn' <?php if ($obj{"risk_neglect_rn"} == "on") {echo "checked";};?>>&nbsp;<b>No</b>
    183. 

  183. 	<img src="../../../images/space.gif" width="5" height="1">
    184. 

  184. 	<b>If yes, client is </b>&nbsp;<input type=checkbox name='risk_neglect_cv' <?php if ($obj{"risk_neglect_cv"} == "on") {echo "checked";};?>>&nbsp;<b>victum</b>
    185. 

  185. 	&nbsp;<input type=checkbox name='risk_neglect_cp' <?php if ($obj{"risk_neglect_cp"} == "on") {echo "checked";};?>>&nbsp;<b>perpetrator</b><br>
    186. 

  186. 	<input type=checkbox name='risk_neglect_cb' <?php if ($obj{"risk_neglect_cb"} == "on") {echo "checked";};?>>&nbsp;<b>Both</b>&nbsp;
    187. 

  187. 	<img src="../../../images/space.gif" width="5" height="1">
    188. 

  188. 	<input type=checkbox name='risk_neglect_cn' <?php if ($obj{"risk_neglect_cn"} == "on") {echo "checked";};?>>&nbsp;<b>neither, but abuse exists in family</b>&nbsp;<br>
    189. 

  189. <br>
    190. 

  190. 

  191. 	<b>If risk exists:</b>&nbsp;client&nbsp;<input type=checkbox name='risk_exists_c' <?php if ($obj{"risk_exists_c"} == "on") {echo "checked";};?>><b>can</b>&nbsp;
    192. 

  192. 	<img src="../../../images/space.gif" width="5" height="1">
    193. 

  193. 	<input type=checkbox name='risk_exists_cn' <?php if ($obj{"risk_exists_cn"} == "on") {echo "checked";};?>>&nbsp;<b>cannot</b>&nbsp;
    194. 

  194. 	<b>meaningfully agree to a contract not to harm</b><br>
    195. 

  195. 	<input type=checkbox name='risk_exists_s' <?php if ($obj{"risk_exists_s"} == "on") {echo "checked";};?>>&nbsp;<b>self</b>
    196. 

  196. 	<img src="../../../images/space.gif" width="5" height="1">
    197. 

  197. 	<input type=checkbox name='risk_exists_o' <?php if ($obj{"risk_exists_o"} == "on") {echo "checked";};?>>&nbsp;<b>others</b>
    198. 

  198. 	<img src="../../../images/space.gif" width="5" height="1">
    199. 

  199. 	<input type=checkbox name='risk_exists_b' <?php if ($obj{"risk_exists_b"} == "on") {echo "checked";};?>>&nbsp;<b>both</b><br><br>
    200. 

  200. 	
    201. 

  201.     <b>Risk to community (criminal):</b><br>
    202. 

  202.     <textarea cols=100 rows=3 wrap=virtual name="risk_community" ><?php echo stripslashes($obj{"risk_community"});?></textarea><br>
    203. 

  203. 	
    204. 

  204. <b><u>Assessment Recommendations:</u></b><br><br>
    205. 

  205. 

  206. <b>Outpatient Psychotherapy:</b>
    207. 

  207. 	<img src="../../../images/space.gif" width="5" height="1">
    208. 

  208. 	<input type=checkbox name='recommendations_psy_i' <?php if ($obj{"recommendations_psy_i"} == "on") {echo "checked";};?>>&nbsp;<b>Individual</b>
    209. 

  209. 	<img src="../../../images/space.gif" width="5" height="1">
    210. 

  210. 	<input type=checkbox name='recommendations_psy_f' <?php if ($obj{"recommendations_psy_f"} == "on") {echo "checked";};?>>&nbsp;<b>Family</b>
    211. 

  211. 	<img src="../../../images/space.gif" width="5" height="1">
    212. 

  212. 	<input type=checkbox name='recommendations_psy_m' <?php if ($obj{"recommendations_psy_m"} == "on") {echo "checked";};?>>&nbsp;<b>Marital/relational</b>
    213. 

  213. 	<img src="../../../images/space.gif" width="5" height="1">
    214. 

  214. 	<input type=checkbox name='recommendations_psy_o' <?php if ($obj{"recommendations_psy_o"} == "on") {echo "checked";};?>>&nbsp;<b>Other</b><br>
    215. 

  215.     <textarea cols=100 rows=3 wrap=virtual name="recommendations_psy_notes" ><?php echo stripslashes($obj{"recommendations_psy_notes"});?></textarea><br>
    216. 

  216. 

  217. <b>Date report sent to referral source:</b>
    218. 

  218. 	<img src="../../../images/space.gif" width="5" height="1">
    219. 

  219. 	<input type="text" name='refer_date' value="<?echo stripslashes($obj{"refer_date"});?>">
    220. 

  220. 	<img src="../../../images/space.gif" width="5" height="1">
    221. 

  221. 	<b>Parent/Guardian:</b>
    222. 

  222. 	<img src="../../../images/space.gif" width="5" height="1">
    223. 

  223.     <input type="text" name='parent' value="<?echo stripslashes($obj{"parent"});?>">
    224. 

  224. <br>
    225. 

  225. 

  226. <b>Level of supervision needed:</b>
    227. 

  227. 	<br>
    228. 

  228. 	<textarea cols=100 rows=1 wrap=virtual name="supervision_level" ><?php echo stripslashes($obj{"supervision_level"});?></textarea><br>
    229. 

  229. 	<b>Type of program:</b><br>
    230. 

  230. 	<textarea cols=100 rows=1 wrap=virtual name="supervision_type" ><?php echo stripslashes($obj{"supervision_type"});?></textarea><br>
    231. 

  231. 

  232. <b>Residential or long-term placement recommended:</b>
    233. 

  233. 	<img src="../../../images/space.gif" width="5" height="1">
    234. 

  234. 	<textarea cols=100 rows=1 wrap=virtual name="supervision_res" ><?php echo stripslashes($obj{"supervision_res"});?></textarea><br>
    235. 

  235. 	<b>Support services needed:</b><br>
    236. 

  236. 	<textarea cols=100 rows=1 wrap=virtual name="supervision_services" ><?php echo stripslashes($obj{"supervision_services"});?></textarea><br>
    237. 

  237. 		
    238. 

  238. 	<input type=checkbox name='support_ps' <?php if ($obj{"support_ps"} == "on") {echo "checked";};?>>&nbsp;<b>Parenting skills/child management</b>
    239. 

  239. 	<img src="../../../images/space.gif" width="5" height="1">
    240. 

  240.     <input type=checkbox name='support_cs' <?php if ($obj{"support_cs"} == "on") {echo "checked";};?>>&nbsp;<b>Communication skills</b>
    241. 

  241. 	<img src="../../../images/space.gif" width="5" height="1">
    242. 

  242.     <input type=checkbox name='support_sm' <?php if ($obj{"support_sm"} == "on") {echo "checked";};?>>&nbsp;<b>Stress management</b><br>
    243. 

  243. 

  244. 	<input type=checkbox name='support_a' <?php if ($obj{"support_a"} == "on") {echo "checked";};?>>&nbsp;<b>Assertiveness</b>
    245. 

  245. 	<img src="../../../images/space.gif" width="5" height="1">
    246. 

  246.     <input type=checkbox name='support_o' <?php if ($obj{"support_o"} == "on") {echo "checked";};?>>&nbsp;<b>Other</b><br>
    247. 

  247. 	<textarea cols=100 rows=1 wrap=virtual name="support_ol" ><?php echo stripslashes($obj{"support_ol"});?></textarea><br><br>
    248. 

  248. 	
    249. 

  249. <b>Legal Services:</b>
    250. 

  250. 	<img src="../../../images/space.gif" width="5" height="1">
    251. 

  251.     <input type=checkbox name='legal_op' <?php if ($obj{"legal_op"} == "on") {echo "checked";};?>>&nbsp;<b>Offender program</b>
    252. 

  252. 	<img src="../../../images/space.gif" width="5" height="1">
    253. 

  253.     <input type=checkbox name='legal_so' <?php if ($obj{"legal_so"} == "on") {echo "checked";};?>>&nbsp;<b>Sex Offender Groups</b>
    254. 

  254. 	<img src="../../../images/space.gif" width="5" height="1">
    255. 

  255.     <input type=checkbox name='legal_sa' <?php if ($obj{"legal_sa"} == "on") {echo "checked";};?>>&nbsp;<b>Substance abuse</b><br>
    256. 

  256. 	
    257. 

  257. 	<input type=checkbox name='legal_ve' <?php if ($obj{"legal_ve"} == "on") {echo "checked";};?>>&nbsp;<b>Victum empathy group</b>
    258. 

  258. 	<img src="../../../images/space.gif" width="5" height="1">
    259. 

  259.     <input type=checkbox name='legal_ad' <?php if ($obj{"legal_ad"} == "on") {echo "checked";};?>>&nbsp;<b>Referral to advocate</b>
    260. 

  260. 	<img src="../../../images/space.gif" width="5" height="1">
    261. 

  261.     <input type="text" name='legal_adl' value="<?echo stripslashes($obj{"legal_adl"});?>">
    262. 

  262. 	<img src="../../../images/space.gif" width="5" height="1"><br>
    263. 

  263.     <input type=checkbox name='legal_o' <?php if ($obj{"legal_o"} == "on") {echo "checked";};?>>&nbsp;<b>Other:</b>
    264. 

  264. 	
    265. 

  265. 	<br>
    266. 

  266. 

  267.     <b>Other:</b><br>
    268. 

  268. 	<textarea cols=100 rows=1 wrap=virtual name="legal_ol" ><?php echo stripslashes($obj{"legal_ol"});?></textarea><br><br>
    269. 

  269. 	
    270. 

  270. <b><u>Referrals for Continuing Services</u></b><br><br>
    271. 

  271. 

  272. <b>Psychiatric Evaluation Psychotropic Medications:</b><br>
    273. 

  273. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_pepm" ><?php echo stripslashes($obj{"referrals_pepm"});?></textarea><br><br>
    274. 

  274. 

  275. <b>Medical Care:</b><br>
    276. 

  276. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_mc" ><?php echo stripslashes($obj{"referrals_mc"});?></textarea><br><br>
    277. 

  277. 	
    278. 

  278. <b>Educational/vocational services:</b><br>
    279. 

  279. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_vt" ><?php echo stripslashes($obj{"referrals_vt"});?></textarea><br><br>
    280. 

  280. 	
    281. 

  281. <b>Other:</b><br>
    282. 

  282. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_o" ><?php echo stripslashes($obj{"referrals_o"});?></textarea><br><br>
    283. 

  283. 

  284. <b>Current use of resources/services from other community agencies:</b><br>
    285. 

  285. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_cu" ><?php echo stripslashes($obj{"referrals_cu"});?></textarea><br><br>
    286. 

  286. 	
    287. 

  287. <b>Documents to be obtainded (Release of Information Required):</b><br>
    288. 

  288. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_docs" ><?php echo stripslashes($obj{"referrals_docs"});?></textarea><br><br>
    289. 

  289. 	
    290. 

  290. <b>Other needed resources and services:</b><br>
    291. 

  291. 	<textarea cols=100 rows=2 wrap=virtual name="referrals_or" ><?php echo stripslashes($obj{"referrals_or"});?></textarea><br><br>
    292. 

  292. 

  293. <?php /* From New */ ?>
    294. 

  294. 

  295. <br>
    296. 

  296. <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
    297. 

  297. <br>
    298. 

  298. <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
    299. 

  299.  onclick="top.restoreSession()">[Don't Save Changes]</a>
    300. 

  300. </form>
    301. 

  301. <?php
    302. 

  302. formFooter();
    303. 

  303. ?>
    304. 

  304.