/contrib/forms/assessment_intake/view.php
PHP | 303 lines | 300 code | 3 blank | 0 comment | 0 complexity | 918a12660a10823e80dc39fd6eb30832 MD5 | raw file
1<!-- Forms generated from formsWiz -->
2<?php
3include_once("../../globals.php");
4?>
5<html><head>
6<?php html_header_show();?>
7<link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
8</head>
9<body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
10<?php
11include_once("$srcdir/api.inc");
12
13$obj = formFetch("form_assessment_intake", $_GET["id"]);
14
15?>
16<form method=post action="<?echo $rootdir?>/forms/assessment_intake/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
17<span class="title"><center><b>Assessment and Intake</b></center></span><br><br>
18
19<a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
20<br>
21<a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
22 onclick="top.restoreSession()">[Don't Save Changes]</a>
23<br></br>
24
25<?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
26$result = SqlFetchArray($res); ?>
27<b>Name:</b> <?php echo $result['fname'] . ' ' . $result['mname'] . ' ' . $result['lname'];?>
28<img src="../../../images/space.gif" width="572" height="1">
29<b>Date:</b> <?php print date('m/d/y'); ?><br><br>
30<b>SSN:</b> <?php echo $result['ss'];?><img src="../../../images/space.gif" width="172" height="1">
31<b>DCN:</b> <input type="entry" name="dcn" value="<?php echo stripslashes($obj{"dcn"});?>"><img src="../../../images/space.gif" width="125" height="1">
32<label><b>Location:</b> <input type="entry" name="location" value="<?php echo stripslashes($obj{"location"});?>"></label><br><br>
33<b>Address:</b> <?php echo $result['street'] . ', ' . $result['city'] . ', ' . $result['state'] . ' ' . $result['postal_code'];?><br><br>
34<b>Telephone Number:</b> <?php echo $result['phone_home'];?><img src="../../../images/space.gif" width="400" height="1">
35<b>Date of Birth:</b> <?php echo $result['DOB'];?><br><br>
36<label><b>Time In:</b> <input type="entry" name="time_in" value="<?php echo stripslashes($obj{"time_in"});?>"></label><img src="../../../images/space.gif" width="65" height="1">
37<label><b>Time Out:</b> <input type="entry" name="time_out" value="<?php echo stripslashes($obj{"time_out"});?>"></label><img src="../../../images/space.gif" width="65" height="1">
38<label><b>Referral Source:</b> <input type="entry" name="referral_source" value="<?php echo stripslashes($obj{"referral_source"});?>"></label><br><br>
39<b>Purpose:</b> <input type=checkbox name='new_client_eval' <?php if ($obj{"new_client_eval"} == "on") {echo "checked";};?> ><b>New client evaluation</b><img src="../../../images/space.gif" width="10" height="1">
40<input type=checkbox name='readmission' <?php if ($obj{"readmission"} == "on") {echo "checked";};?> ><b>Readmission</b><img src="../../../images/space.gif" width="35" height="1">
41<input type=checkbox name='consultation' <?php if ($obj{"consultation"} == "on") {echo "checked";};?> ><b>Consultation</b><br><br>
42<label><b>Copy sent to:</b> <input type="entry" name="copy_sent_to" value="<?echo stripslashes($obj{"copy_sent_to"});?>"></label><br><br>
43<b>Why is Assessment being requested (Goals and treatment expectations of the individual requesting services):</b><br>
44<textarea cols=100 rows=3 name="reason_why" ><?php echo stripslashes($obj{"reason_why"});?></textarea><br>
45<b>Behavior that led to Assessment:</b><br>
46<textarea cols=100 rows=5 wrap=virtual name="behavior_led_to" ><?php echo stripslashes($obj{"behavior_led_to"});?></textarea><br><br>
47<b><u></u>Areas of Functioning:</b><br><br>
48<b>School/Work:</b><br>
49<textarea cols=100 rows=3 wrap=virtual name="school_work" ><?php echo stripslashes($obj{"school_work"});?></textarea><br><br>
50<b>Personal Relationships (Intimate):</b>
51<textarea cols=100 rows=4 wrap=virtual name="personal_relationships" ><?php echo stripslashes($obj{"personal_relationships"});?></textarea><br><br>
52<b>Family Relationships:</b>
53<input type=checkbox name='fatherc' <?php if ($obj{"fatherc"} == "on") {echo "checked";};?> > <b>Father involved/present/absent (Describe relationship)</b><br>
54<textarea cols=100 rows=3 wrap=virtual name="father_involved" ><?php echo stripslashes($obj{"father_involved"});?></textarea><br>
55<input type=checkbox name='motherc' <?php if ($obj{"motherc"} == "on") {echo "checked";};?> > <b>Mother involved/present/absent (Describe relationship)</b><br>
56<textarea cols=100 rows=3 wrap=virtual name="mother_involved" ><?php echo stripslashes($obj{"mother_involved"});?></textarea><br><br>
57<b>Number of children:</b> <input type="entry" name="number_children"value="<?php echo stripslashes($obj{"number_children"});?>"><br><b>Names, ages, quality of relationship(s):</b><br>
58<textarea cols=100 rows=3 wrap=virtual name="siblings" ><?php echo stripslashes($obj{"siblings"});?></textarea><br><br>
59<b>Other family relationships:</b><br>
60<textarea cols=100 rows=2 wrap=virtual name="other_relationships" ><?php echo stripslashes($obj{"other_relationships"});?></textarea><br><br>
61<b>Social Relationships (Peers/Friends):</b><br>
62<textarea cols=100 rows=3 wrap=virtual name="social_relationships" ><?php echo stripslashes($obj{"social_relationships"});?></textarea><br><br>
63<b>Psychological/Personal Functioning (Current symptons):</b><br>
64<textarea cols=100 rows=3 wrap=virtual name="current_symptoms" ><?php echo stripslashes($obj{"current_symptoms"});?></textarea><br><br>
65<b>Personal resources and strengths (including the availability & use of family and peers):</b><br>
66<textarea cols=100 rows=3 wrap=virtual name="personal_strengths" ><?php echo stripslashes($obj{"personal_strengths"});?></textarea><br><br>
67<b>Spiritual:</b> <input type="entry" name="spiritual" value="<?echo stripslashes($obj{"spiritual"});?>"> <img src="../../../images/space.gif" width="35" height="1">
68<b>Legal:</b> <input type="entry" name="legal" value="<?echo stripslashes($obj{"legal"});?>"><br><br>
69<b>Prior Mental Health History/Treatment:</b><br>
70<textarea cols=100 rows=3 wrap=virtual name="prior_history" ><?php echo stripslashes($obj{"prior_history"});?></textarea><br><br>
71<b>Number of admissions:</b> <input type="entry" name="number_admitt" value="<?echo stripslashes($obj{"number_admitt"});?>"> <img src="../../../images/space.gif" width="35" height="1">
72<b>Types of admissions:</b> <input type="entry" name="type_admitt" value="<?echo stripslashes($obj{"type_admitt"});?>"><br><br>
73<b>Alcohol and substance use for the past 30 days:</b><br>
74<textarea cols=100 rows=3 wrap=virtual name="substance_use" ><?php echo stripslashes($obj{"substance_use"});?></textarea><br><br>
75<b>Substance abuse history (Include duration, patterns, and consequences of use):</b><br>
76<textarea cols=100 rows=3 wrap=virtual name="substance_abuse" ><?php echo stripslashes($obj{"substance_abuse"});?></textarea><br><br>
77<b><u>Diagnoses</u></b><br><br>
78<b>Axis I:</b><br>
79<textarea cols=100 rows=3 wrap=virtual name="axis1" ><?php echo stripslashes($obj{"axis1"});?></textarea><br><br>
80<b>Axis II:</b><br>
81<textarea cols=100 rows=3 wrap=virtual name="axis2" ><?php echo stripslashes($obj{"axis2"});?></textarea><br><br>
82<b>Axis III:</b><br>
83<textarea cols=100 rows=3 wrap=virtual name="axis3" ><?php echo stripslashes($obj{"axis3"});?></textarea><br><br>
84<b><u>Allergies/Adverse reactions to medications:</u></b> <input type="entry" name="allergies" value="<?echo stripslashes($obj{"allergies"});?>"><br><br>
85<b>Axis IV Psychosocial and environmental problems in the last year:</b><br>
86<input type=checkbox name='ax4_prob_support_group' <?php if ($obj{"ax4_prob_support_group"} == "on") {echo "checked";};?> > <b>Problems with primary support group</b>
87<img src="../../../images/space.gif" width="35" height="1">
88<input type=checkbox name='ax4_prob_soc_env' <?php if ($obj{"ax4_prob_soc_env"} == "on") {echo "checked";};?> > <b>Problems related to the social environment</b><br>
89
90<input type=checkbox name='ax4_educational_prob' <?php if ($obj{"ax4_educational_prob"} == "on") {echo "checked";};?> > <b>Educational problems</b>
91<img src="../../../images/space.gif" width="5" height="1">
92<input type=checkbox name='ax4_occ_prob' <?php if ($obj{"ax4_occ_prob"} == "on") {echo "checked";};?> > <b>Occupational problems</b>
93<img src="../../../images/space.gif" width="5" height="1">
94<input type=checkbox name='ax4_housing' <?php if ($obj{"ax4_housing"} == "on") {echo "checked";};?> > <b>Housing problems</b>
95<img src="../../../images/space.gif" width="5" height="1">
96<input type=checkbox name='ax4_economic' <?php if ($obj{"ax4_economic"} == "on") {echo "checked";};?> > <b>Economic problems</b><br>
97<input type=checkbox name='ax4_access_hc' <?php if ($obj{"ax4_access_hc"} == "on") {echo "checked";};?> > <b>Problems with access to health care services</b>
98<img src="../../../images/space.gif" width="5" height="1">
99<input type=checkbox name='ax4_legal' <?php if ($obj{"ax4_legal"} == "on") {echo "checked";};?> > <b>Problems related to interaction with the legal system/crime</b><br>
100<input type=checkbox name='ax4_other_cb' <?php if ($obj{"ax4_other_cb"} == "on") {echo "checked";};?> > <b>Other (specify):</b><br>
101<textarea cols=100 rows=2 wrap=virtual name="ax4_other" ><?php echo stripslashes($obj{"ax4_other"});?></textarea><br><br>
102<b>Axis V Global Assessment of Functioning (GAF) Scale (100 down to 0):</b>
103<img src="../../../images/space.gif" width="5" height="1"><br>
104<b>Currently</b><input type="entry" name="ax5_current" value="<?echo stripslashes($obj{"ax5_current"});?>">
105<img src="../../../images/space.gif" width="5" height="1">
106<b>Past Year</b><input type="entry" name="ax5_past" value="<?echo stripslashes($obj{"ax5_current"});?>"><br><br>
107<b><u>Assessment of Currently Known Risk Factors:</u></b><br><br>
108<b>Suicide:</b><br><input type=checkbox name='risk_suicide_na' <?php if ($obj{"risk_suicide_na"} == "on") {echo "checked";};?> > <b>Not Assessed</b>
109 <img src="../../../images/space.gif" width="5" height="1">
110 <b>Behaviors:</b>
111 <img src="../../../images/space.gif" width="5" height="1">
112 <input type=checkbox name='risk_suicide_nk' <?php if ($obj{"risk_suicide_nk"} == "on") {echo "checked";};?> > <b>Not Known</b>
113 <img src="../../../images/space.gif" width="5" height="1">
114 <input type=checkbox name='risk_suicide_io' <?php if ($obj{"risk_suicide_io"} == "on") {echo "checked";};?> > <b>Ideation only</b>
115 <img src="../../../images/space.gif" width="5" height="1">
116 <input type=checkbox name='risk_suicide_plan' <?php if ($obj{"risk_suicide_plan"} == "on") {echo "checked";};?> > <b>Plan</b><br>
117 <img src="../../../images/space.gif" width="100" height="1">
118 <input type=checkbox name='risk_suicide_iwom' <?php if ($obj{"risk_suicide_iwom"} == "on") {echo "checked";};?> > <b>Intent without means</b>
119 <img src="../../../images/space.gif" width="5" height="1">
120 <input type=checkbox name='risk_suicide_iwm' <?php if ($obj{"risk_suicide_iwm"} == "on") {echo "checked";};?> > <b>Intent with means</b><br>
121<br>
122<b>Homocide:</b><br><input type=checkbox name='risk_homocide_na' <?php if ($obj{"risk_homocide_na"} == "on") {echo "checked";};?> > <b>Not Assessed</b>
123 <img src="../../../images/space.gif" width="5" height="1">
124 <b>Behaviors:</b>
125 <img src="../../../images/space.gif" width="5" height="1">
126 <input type=checkbox name='risk_homocide_nk' <?php if ($obj{"risk_homocide_nk"} == "on") {echo "checked";};?> > <b>Not Known</b>
127 <img src="../../../images/space.gif" width="5" height="1">
128 <input type=checkbox name='risk_homocide_io' <?php if ($obj{"risk_homocide_io"} == "on") {echo "checked";};?> > <b>Ideation only</b>
129 <img src="../../../images/space.gif" width="5" height="1">
130 <input type=checkbox name='risk_homocide_plan' <?php if ($obj{"risk_homocide_plan"} == "on") {echo "checked";};?> > <b>Plan</b><br>
131 <img src="../../../images/space.gif" width="100" height="1">
132 <input type=checkbox name='risk_homocide_iwom' <?php if ($obj{"risk_homocide_iwom"} == "on") {echo "checked";};?> > <b>Intent without means</b>
133 <img src="../../../images/space.gif" width="5" height="1">
134 <input type=checkbox name='risk_homocide_iwm' <?php if ($obj{"risk_homocide_iwm"} == "on") {echo "checked";};?> > <b>Intent with means</b><br>
135<br>
136<b>Compliance with treatment:</b><br><input type=checkbox name='risk_compliance_na' <?php if ($obj{"risk_compliance_na"} == "on") {echo "checked";};?> > <b>Not Assessed</b>
137 <img src="../../../images/space.gif" width="5" height="1">
138 <input type=checkbox name='risk_compliance_fc' <?php if ($obj{"risk_compliance_fc"} == "on") {echo "checked";};?> > <b>Full compliance</b>
139 <img src="../../../images/space.gif" width="5" height="1">
140 <input type=checkbox name='risk_compliance_mc' <?php if ($obj{"risk_compliance_mc"} == "on") {echo "checked";};?> > <b>Minimal compliance</b>
141 <img src="../../../images/space.gif" width="5" height="1">
142 <input type=checkbox name='risk_compliance_moc' <?php if ($obj{"risk_compliance_moc"} == "on") {echo "checked";};?> > <b>Moderate compliance</b><br>
143 <img src="../../../images/space.gif" width="100" height="1">
144 <input type=checkbox name='risk_compliance_var' <?php if ($obj{"risk_compliance_var"} == "on") {echo "checked";};?> > <b>Variable</b>
145 <img src="../../../images/space.gif" width="5" height="1">
146 <input type=checkbox name='risk_compliance_no' <?php if ($obj{"risk_compliance_no"} == "on") {echo "checked";};?> > <b>Little or no compliance</b><br>
147<br>
148<b>Substance Abuse:</b><br><input type=checkbox name='risk_substance_na' <?php if ($obj{"risk_substance_na"} == "on") {echo "checked";};?> > <b>Not Assessed</b>
149 <img src="../../../images/space.gif" width="5" height="1">
150 <input type=checkbox name='risk_substance_none' <?php if ($obj{"risk_substance_none"} == "on") {echo "checked";};?> > <b>None/normal use:</b><br>
151 <textarea cols=100 rows=1 wrap=virtual name="risk_normal_use" ><?php echo stripslashes($obj{"risk_normal_use"});?></textarea><br>
152 <input type=checkbox name='risk_substance_ou' <?php if ($obj{"risk_substance_ou"} == "on") {echo "checked";};?> > <b>Overuse</b>
153 <img src="../../../images/space.gif" width="5" height="1">
154 <input type=checkbox name='risk_substance_dp' <?php if ($obj{"risk_substance_dp"} == "on") {echo "checked";};?> > <b>Dependence</b>
155 <img src="../../../images/space.gif" width="5" height="1">
156 <input type=checkbox name='risk_substance_ur' <?php if ($obj{"risk_substance_ur"} == "on") {echo "checked";};?> > <b>Unstable remission of abuse</b>
157 <img src="../../../images/space.gif" width="5" height="1">
158 <input type=checkbox name='risk_substance_ab' <?php if ($obj{"risk_substance_ab"} == "on") {echo "checked";};?> > <b>Abuse</b><br>
159<br>
160<b>Current physical or sexual abuse:</b><br><input type=checkbox name='risk_sexual_na' <?php if ($obj{"risk_sexual_na"} == "on") {echo "checked";};?> > <b>Not Assessed</b>
161 <img src="../../../images/space.gif" width="5" height="1">
162 <input type=checkbox name='risk_sexual_y' <?php if ($obj{"risk_sexual_y"} == "on") {echo "checked";};?>> <b>Yes</b>
163 <img src="../../../images/space.gif" width="5" height="1">
164 <input type=checkbox name='risk_sexual_n' <?php if ($obj{"risk_sexual_n"} == "on") {echo "checked";};?>> <b>No</b><br>
165 <b>Legally reportable?</b> <input type=checkbox name='risk_sexual_ry' <?php if ($obj{"risk_sexual_ry"} == "on") {echo "checked";};?>> <b>Yes</b>
166 <img src="../../../images/space.gif" width="5" height="1">
167 <input type=checkbox name='risk_sexual_rn' <?php if ($obj{"risk_sexual_rn"} == "on") {echo "checked";};?>> <b>No</b>
168 <img src="../../../images/space.gif" width="5" height="1">
169 <b>If yes, client is </b> <input type=checkbox name='risk_sexual_cv' <?php if ($obj{"risk_sexual_cv"} == "on") {echo "checked";};?>> <b>victum</b>
170 <input type=checkbox name='risk_sexual_cp' <?php if ($obj{"risk_sexual_cp"} == "on") {echo "checked";};?>> <b>perpetrator</b><br>
171 <input type=checkbox name='risk_sexual_b' <?php if ($obj{"risk_sexual_b"} == "on") {echo "checked";};?>> <b>Both</b>
172 <img src="../../../images/space.gif" width="5" height="1">
173 <input type=checkbox name='risk_sexual_nf' <?php if ($obj{"risk_sexual_nf"} == "on") {echo "checked";};?>> <b>neither, but abuse exists in family</b> <br>
174<br>
175<b>Current child/elder abuse:</b><br><input type=checkbox name='risk_neglect_na' <?php if ($obj{"risk_neglect_na"} == "on") {echo "checked";};?> > <b>Not Assessed</b>
176 <img src="../../../images/space.gif" width="5" height="1">
177 <input type=checkbox name='risk_neglect_y' <?php if ($obj{"risk_neglect_y"} == "on") {echo "checked";};?>> <b>Yes</b>
178 <img src="../../../images/space.gif" width="5" height="1">
179 <input type=checkbox name='risk_neglect_n' <?php if ($obj{"risk_neglect_n"} == "on") {echo "checked";};?>> <b>No</b><br>
180 <b>Legally reportable?</b> <input type=checkbox name='risk_neglect_ry' <?php if ($obj{"risk_neglect_ry"} == "on") {echo "checked";};?>> <b>Yes</b>
181 <img src="../../../images/space.gif" width="5" height="1">
182 <input type=checkbox name='risk_neglect_rn' <?php if ($obj{"risk_neglect_rn"} == "on") {echo "checked";};?>> <b>No</b>
183 <img src="../../../images/space.gif" width="5" height="1">
184 <b>If yes, client is </b> <input type=checkbox name='risk_neglect_cv' <?php if ($obj{"risk_neglect_cv"} == "on") {echo "checked";};?>> <b>victum</b>
185 <input type=checkbox name='risk_neglect_cp' <?php if ($obj{"risk_neglect_cp"} == "on") {echo "checked";};?>> <b>perpetrator</b><br>
186 <input type=checkbox name='risk_neglect_cb' <?php if ($obj{"risk_neglect_cb"} == "on") {echo "checked";};?>> <b>Both</b>
187 <img src="../../../images/space.gif" width="5" height="1">
188 <input type=checkbox name='risk_neglect_cn' <?php if ($obj{"risk_neglect_cn"} == "on") {echo "checked";};?>> <b>neither, but abuse exists in family</b> <br>
189<br>
190
191 <b>If risk exists:</b> client <input type=checkbox name='risk_exists_c' <?php if ($obj{"risk_exists_c"} == "on") {echo "checked";};?>><b>can</b>
192 <img src="../../../images/space.gif" width="5" height="1">
193 <input type=checkbox name='risk_exists_cn' <?php if ($obj{"risk_exists_cn"} == "on") {echo "checked";};?>> <b>cannot</b>
194 <b>meaningfully agree to a contract not to harm</b><br>
195 <input type=checkbox name='risk_exists_s' <?php if ($obj{"risk_exists_s"} == "on") {echo "checked";};?>> <b>self</b>
196 <img src="../../../images/space.gif" width="5" height="1">
197 <input type=checkbox name='risk_exists_o' <?php if ($obj{"risk_exists_o"} == "on") {echo "checked";};?>> <b>others</b>
198 <img src="../../../images/space.gif" width="5" height="1">
199 <input type=checkbox name='risk_exists_b' <?php if ($obj{"risk_exists_b"} == "on") {echo "checked";};?>> <b>both</b><br><br>
200
201 <b>Risk to community (criminal):</b><br>
202 <textarea cols=100 rows=3 wrap=virtual name="risk_community" ><?php echo stripslashes($obj{"risk_community"});?></textarea><br>
203
204<b><u>Assessment Recommendations:</u></b><br><br>
205
206<b>Outpatient Psychotherapy:</b>
207 <img src="../../../images/space.gif" width="5" height="1">
208 <input type=checkbox name='recommendations_psy_i' <?php if ($obj{"recommendations_psy_i"} == "on") {echo "checked";};?>> <b>Individual</b>
209 <img src="../../../images/space.gif" width="5" height="1">
210 <input type=checkbox name='recommendations_psy_f' <?php if ($obj{"recommendations_psy_f"} == "on") {echo "checked";};?>> <b>Family</b>
211 <img src="../../../images/space.gif" width="5" height="1">
212 <input type=checkbox name='recommendations_psy_m' <?php if ($obj{"recommendations_psy_m"} == "on") {echo "checked";};?>> <b>Marital/relational</b>
213 <img src="../../../images/space.gif" width="5" height="1">
214 <input type=checkbox name='recommendations_psy_o' <?php if ($obj{"recommendations_psy_o"} == "on") {echo "checked";};?>> <b>Other</b><br>
215 <textarea cols=100 rows=3 wrap=virtual name="recommendations_psy_notes" ><?php echo stripslashes($obj{"recommendations_psy_notes"});?></textarea><br>
216
217<b>Date report sent to referral source:</b>
218 <img src="../../../images/space.gif" width="5" height="1">
219 <input type="text" name='refer_date' value="<?echo stripslashes($obj{"refer_date"});?>">
220 <img src="../../../images/space.gif" width="5" height="1">
221 <b>Parent/Guardian:</b>
222 <img src="../../../images/space.gif" width="5" height="1">
223 <input type="text" name='parent' value="<?echo stripslashes($obj{"parent"});?>">
224<br>
225
226<b>Level of supervision needed:</b>
227 <br>
228 <textarea cols=100 rows=1 wrap=virtual name="supervision_level" ><?php echo stripslashes($obj{"supervision_level"});?></textarea><br>
229 <b>Type of program:</b><br>
230 <textarea cols=100 rows=1 wrap=virtual name="supervision_type" ><?php echo stripslashes($obj{"supervision_type"});?></textarea><br>
231
232<b>Residential or long-term placement recommended:</b>
233 <img src="../../../images/space.gif" width="5" height="1">
234 <textarea cols=100 rows=1 wrap=virtual name="supervision_res" ><?php echo stripslashes($obj{"supervision_res"});?></textarea><br>
235 <b>Support services needed:</b><br>
236 <textarea cols=100 rows=1 wrap=virtual name="supervision_services" ><?php echo stripslashes($obj{"supervision_services"});?></textarea><br>
237
238 <input type=checkbox name='support_ps' <?php if ($obj{"support_ps"} == "on") {echo "checked";};?>> <b>Parenting skills/child management</b>
239 <img src="../../../images/space.gif" width="5" height="1">
240 <input type=checkbox name='support_cs' <?php if ($obj{"support_cs"} == "on") {echo "checked";};?>> <b>Communication skills</b>
241 <img src="../../../images/space.gif" width="5" height="1">
242 <input type=checkbox name='support_sm' <?php if ($obj{"support_sm"} == "on") {echo "checked";};?>> <b>Stress management</b><br>
243
244 <input type=checkbox name='support_a' <?php if ($obj{"support_a"} == "on") {echo "checked";};?>> <b>Assertiveness</b>
245 <img src="../../../images/space.gif" width="5" height="1">
246 <input type=checkbox name='support_o' <?php if ($obj{"support_o"} == "on") {echo "checked";};?>> <b>Other</b><br>
247 <textarea cols=100 rows=1 wrap=virtual name="support_ol" ><?php echo stripslashes($obj{"support_ol"});?></textarea><br><br>
248
249<b>Legal Services:</b>
250 <img src="../../../images/space.gif" width="5" height="1">
251 <input type=checkbox name='legal_op' <?php if ($obj{"legal_op"} == "on") {echo "checked";};?>> <b>Offender program</b>
252 <img src="../../../images/space.gif" width="5" height="1">
253 <input type=checkbox name='legal_so' <?php if ($obj{"legal_so"} == "on") {echo "checked";};?>> <b>Sex Offender Groups</b>
254 <img src="../../../images/space.gif" width="5" height="1">
255 <input type=checkbox name='legal_sa' <?php if ($obj{"legal_sa"} == "on") {echo "checked";};?>> <b>Substance abuse</b><br>
256
257 <input type=checkbox name='legal_ve' <?php if ($obj{"legal_ve"} == "on") {echo "checked";};?>> <b>Victum empathy group</b>
258 <img src="../../../images/space.gif" width="5" height="1">
259 <input type=checkbox name='legal_ad' <?php if ($obj{"legal_ad"} == "on") {echo "checked";};?>> <b>Referral to advocate</b>
260 <img src="../../../images/space.gif" width="5" height="1">
261 <input type="text" name='legal_adl' value="<?echo stripslashes($obj{"legal_adl"});?>">
262 <img src="../../../images/space.gif" width="5" height="1"><br>
263 <input type=checkbox name='legal_o' <?php if ($obj{"legal_o"} == "on") {echo "checked";};?>> <b>Other:</b>
264
265 <br>
266
267 <b>Other:</b><br>
268 <textarea cols=100 rows=1 wrap=virtual name="legal_ol" ><?php echo stripslashes($obj{"legal_ol"});?></textarea><br><br>
269
270<b><u>Referrals for Continuing Services</u></b><br><br>
271
272<b>Psychiatric Evaluation Psychotropic Medications:</b><br>
273 <textarea cols=100 rows=2 wrap=virtual name="referrals_pepm" ><?php echo stripslashes($obj{"referrals_pepm"});?></textarea><br><br>
274
275<b>Medical Care:</b><br>
276 <textarea cols=100 rows=2 wrap=virtual name="referrals_mc" ><?php echo stripslashes($obj{"referrals_mc"});?></textarea><br><br>
277
278<b>Educational/vocational services:</b><br>
279 <textarea cols=100 rows=2 wrap=virtual name="referrals_vt" ><?php echo stripslashes($obj{"referrals_vt"});?></textarea><br><br>
280
281<b>Other:</b><br>
282 <textarea cols=100 rows=2 wrap=virtual name="referrals_o" ><?php echo stripslashes($obj{"referrals_o"});?></textarea><br><br>
283
284<b>Current use of resources/services from other community agencies:</b><br>
285 <textarea cols=100 rows=2 wrap=virtual name="referrals_cu" ><?php echo stripslashes($obj{"referrals_cu"});?></textarea><br><br>
286
287<b>Documents to be obtainded (Release of Information Required):</b><br>
288 <textarea cols=100 rows=2 wrap=virtual name="referrals_docs" ><?php echo stripslashes($obj{"referrals_docs"});?></textarea><br><br>
289
290<b>Other needed resources and services:</b><br>
291 <textarea cols=100 rows=2 wrap=virtual name="referrals_or" ><?php echo stripslashes($obj{"referrals_or"});?></textarea><br><br>
292
293<?php /* From New */ ?>
294
295<br>
296<a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
297<br>
298<a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
299 onclick="top.restoreSession()">[Don't Save Changes]</a>
300</form>
301<?php
302formFooter();
303?>