contrib/forms/assessment_intake/view.php

   1 <!-- Forms generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 ?>
   5 <html><head>
   6 <?php html_header_show();?>
   7 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <?php
  11 include_once("$srcdir/api.inc");
  12
  13 $obj = formFetch("form_assessment_intake", $_GET["id"]);
  14
  15 ?>
  16 <form method=post action="<?php echo $rootdir?>/forms/assessment_intake/save.php?mode=update&id=<?php 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>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  28 <img src="../../../images/space.gif" width="572" height="1">
  29 <b>Date:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
  30 <b>SSN:</b>&nbsp;<?php echo $result['ss'];?><img src="../../../images/space.gif" width="172" height="1">
  31 <b>DCN:</b>&nbsp;<input type="entry" name="dcn" value="<?php echo stripslashes($obj{"dcn"});?>"><img src="../../../images/space.gif" width="125" height="1">
  32 <label><b>Location:</b>&nbsp;<input type="entry" name="location" value="<?php echo stripslashes($obj{"location"});?>"></label><br><br>
  33 <b>Address:</b>&nbsp; <?php echo $result['street'] . ',&nbsp' . $result['city']  . ',&nbsp' . $result['state'] . '&nbsp;' . $result['postal_code'];?><br><br>
  34 <b>Telephone Number:</b>&nbsp; <?php echo $result['phone_home'];?><img src="../../../images/space.gif" width="400" height="1">
  35 <b>Date of Birth:</b>&nbsp;<?php echo $result['DOB'];?><br><br>
  36 <label><b>Time In:</b>&nbsp;<input type="entry" name="time_in" value="<?php echo stripslashes($obj{"time_in"});?>"></label><img src="../../../images/space.gif" width="65" height="1">
  37 <label><b>Time Out:</b>&nbsp;<input type="entry" name="time_out" value="<?php echo stripslashes($obj{"time_out"});?>"></label><img src="../../../images/space.gif" width="65" height="1">
  38 <label><b>Referral Source:</b>&nbsp;<input type="entry" name="referral_source" value="<?php echo stripslashes($obj{"referral_source"});?>"></label><br><br>
  39 <b>Purpose:</b>&nbsp; <input type=checkbox name='new_client_eval' <?php if ($obj{"new_client_eval"} == "on") {echo "checked";};?>  ><b>New client evaluation</b><img src="../../../images/space.gif" width="10" height="1">
  40 <input type=checkbox name='readmission' <?php if ($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 ($obj{"consultation"} == "on") {echo "checked";};?> ><b>Consultation</b><br><br>
  42 <label><b>Copy sent to:</b>&nbsp;<input type="entry" name="copy_sent_to" value="<?php echo stripslashes($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($obj{"school_work"});?></textarea><br><br>
  50 <b>Personal Relationships (Intimate):</b>&nbsp;
  51 <textarea cols=100 rows=4 wrap=virtual name="personal_relationships" ><?php echo stripslashes($obj{"personal_relationships"});?></textarea><br><br>
  52 <b>Family Relationships:</b>&nbsp; &nbsp;
  53 <input type=checkbox name='fatherc' <?php if ($obj{"fatherc"} == "on") {echo "checked";};?>  >&nbsp;<b>Father involved/present/absent (Describe relationship)</b><br>
  54 <textarea cols=100 rows=3 wrap=virtual name="father_involved" ><?php echo stripslashes($obj{"father_involved"});?></textarea><br>
  55 <input type=checkbox name='motherc' <?php if ($obj{"motherc"} == "on") {echo "checked";};?>  >&nbsp;<b>Mother involved/present/absent (Describe relationship)</b><br>
  56 <textarea cols=100 rows=3 wrap=virtual name="mother_involved" ><?php echo stripslashes($obj{"mother_involved"});?></textarea><br><br>
  57 <b>Number of children:</b>&nbsp;<input type="entry" name="number_children"value="<?php echo stripslashes($obj{"number_children"});?>"><br><b>Names, ages, quality of relationship(s):</b><br>
  58 <textarea cols=100 rows=3 wrap=virtual name="siblings" ><?php echo stripslashes($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>&nbsp;<input type="entry" name="spiritual" value="<?php echo stripslashes($obj{"spiritual"});?>">&nbsp;<img src="../../../images/space.gif" width="35" height="1">
  68 <b>Legal:</b>&nbsp;<input type="entry" name="legal" value="<?php echo stripslashes($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($obj{"prior_history"});?></textarea><br><br>
  71 <b>Number of admissions:</b>&nbsp;<input type="entry" name="number_admitt" value="<?php echo stripslashes($obj{"number_admitt"});?>">&nbsp;<img src="../../../images/space.gif" width="35" height="1">
  72 <b>Types of admissions:</b>&nbsp;<input type="entry" name="type_admitt" value="<?php 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>&nbsp;<input type="entry" name="allergies" value="<?php 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";};?>  >&nbsp;<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 ($obj{"ax4_prob_soc_env"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems related to the social environment</b><br>
  89
  90 <input type=checkbox name='ax4_educational_prob' <?php if ($obj{"ax4_educational_prob"} == "on") {echo "checked";};?>  >&nbsp;<b>Educational problems</b>
  91 <img src="../../../images/space.gif" width="5" height="1">
  92 <input type=checkbox name='ax4_occ_prob' <?php if ($obj{"ax4_occ_prob"} == "on") {echo "checked";};?>  >&nbsp;<b>Occupational problems</b>
  93 <img src="../../../images/space.gif" width="5" height="1">
  94 <input type=checkbox name='ax4_housing' <?php if ($obj{"ax4_housing"} == "on") {echo "checked";};?>  >&nbsp;<b>Housing problems</b>
  95 <img src="../../../images/space.gif" width="5" height="1">
  96 <input type=checkbox name='ax4_economic' <?php if ($obj{"ax4_economic"} == "on") {echo "checked";};?>  >&nbsp;<b>Economic problems</b><br>
  97 <input type=checkbox name='ax4_access_hc' <?php if ($obj{"ax4_access_hc"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems with access to health care services</b>
  98 <img src="../../../images/space.gif" width="5" height="1">
  99 <input type=checkbox name='ax4_legal' <?php if ($obj{"ax4_legal"} == "on") {echo "checked";};?>  >&nbsp;<b>Problems related to interaction with the legal system/crime</b><br>
 100 <input type=checkbox name='ax4_other_cb' <?php if ($obj{"ax4_other_cb"} == "on") {echo "checked";};?>  >&nbsp;<b>Other (specify):</b><br>
 101 <textarea cols=100 rows=2 wrap=virtual name="ax4_other" ><?php echo stripslashes($obj{"ax4_other"});?></textarea><br><br>
 102 <b>Axis V Global Assessment of Functioning (GAF) Scale (100 down to 0):</b>
 103 <img src="../../../images/space.gif" width="5" height="1"><br>
 104 <b>Currently</b><input type="entry" name="ax5_current" value="<?php echo stripslashes($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="<?php 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";};?>  >&nbsp;<b>Not Assessed</b>
 109         <img src="../../../images/space.gif" width="5" height="1">
 110         <b>Behaviors:</b>&nbsp;
 111         <img src="../../../images/space.gif" width="5" height="1">
 112         <input type=checkbox name='risk_suicide_nk' <?php if ($obj{"risk_suicide_nk"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Known</b>
 113         <img src="../../../images/space.gif" width="5" height="1">
 114         <input type=checkbox name='risk_suicide_io' <?php if ($obj{"risk_suicide_io"} == "on") {echo "checked";};?>  >&nbsp;<b>Ideation only</b>
 115         <img src="../../../images/space.gif" width="5" height="1">
 116         <input type=checkbox name='risk_suicide_plan' <?php if ($obj{"risk_suicide_plan"} == "on") {echo "checked";};?>  >&nbsp;<b>Plan</b><br>
 117         <img src="../../../images/space.gif" width="100" height="1">
 118         <input type=checkbox name='risk_suicide_iwom' <?php if ($obj{"risk_suicide_iwom"} == "on") {echo "checked";};?>  >&nbsp;<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 ($obj{"risk_suicide_iwm"} == "on") {echo "checked";};?>  >&nbsp;<b>Intent with means</b><br>
 121 <br>
 122 <b>Homocide:</b><br><input type=checkbox name='risk_homocide_na' <?php if ($obj{"risk_homocide_na"} == "on") {echo "checked";};?>  >&nbsp;<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 ($obj{"risk_homocide_nk"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Known</b>
 127         <img src="../../../images/space.gif" width="5" height="1">
 128         <input type=checkbox name='risk_homocide_io' <?php if ($obj{"risk_homocide_io"} == "on") {echo "checked";};?>  >&nbsp;<b>Ideation only</b>
 129         <img src="../../../images/space.gif" width="5" height="1">
 130         <input type=checkbox name='risk_homocide_plan' <?php if ($obj{"risk_homocide_plan"} == "on") {echo "checked";};?>  >&nbsp;<b>Plan</b><br>
 131         <img src="../../../images/space.gif" width="100" height="1">
 132         <input type=checkbox name='risk_homocide_iwom' <?php if ($obj{"risk_homocide_iwom"} == "on") {echo "checked";};?>  >&nbsp;<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 ($obj{"risk_homocide_iwm"} == "on") {echo "checked";};?>  >&nbsp;<b>Intent with means</b><br>
 135 <br>
 136 <b>Compliance with treatment:</b><br><input type=checkbox name='risk_compliance_na' <?php if ($obj{"risk_compliance_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
 137         <img src="../../../images/space.gif" width="5" height="1">
 138         <input type=checkbox name='risk_compliance_fc' <?php if ($obj{"risk_compliance_fc"} == "on") {echo "checked";};?>  >&nbsp;<b>Full compliance</b>
 139         <img src="../../../images/space.gif" width="5" height="1">
 140         <input type=checkbox name='risk_compliance_mc' <?php if ($obj{"risk_compliance_mc"} == "on") {echo "checked";};?>  >&nbsp;<b>Minimal compliance</b>
 141         <img src="../../../images/space.gif" width="5" height="1">
 142         <input type=checkbox name='risk_compliance_moc' <?php if ($obj{"risk_compliance_moc"} == "on") {echo "checked";};?>  >&nbsp;<b>Moderate compliance</b><br>
 143         <img src="../../../images/space.gif" width="100" height="1">
 144         <input type=checkbox name='risk_compliance_var' <?php if ($obj{"risk_compliance_var"} == "on") {echo "checked";};?>  >&nbsp;<b>Variable</b>
 145         <img src="../../../images/space.gif" width="5" height="1">
 146         <input type=checkbox name='risk_compliance_no' <?php if ($obj{"risk_compliance_no"} == "on") {echo "checked";};?>  >&nbsp;<b>Little or no compliance</b><br>
 147 <br>
 148 <b>Substance Abuse:</b><br><input type=checkbox name='risk_substance_na' <?php if ($obj{"risk_substance_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
 149         <img src="../../../images/space.gif" width="5" height="1">
 150         <input type=checkbox name='risk_substance_none' <?php if ($obj{"risk_substance_none"} == "on") {echo "checked";};?>  >&nbsp;<b>None/normal use:</b><br>
 151     <textarea cols=100 rows=1 wrap=virtual name="risk_normal_use" ><?php echo stripslashes($obj{"risk_normal_use"});?></textarea><br>
 152         <input type=checkbox name='risk_substance_ou' <?php if ($obj{"risk_substance_ou"} == "on") {echo "checked";};?>  >&nbsp;<b>Overuse</b>
 153         <img src="../../../images/space.gif" width="5" height="1">
 154         <input type=checkbox name='risk_substance_dp' <?php if ($obj{"risk_substance_dp"} == "on") {echo "checked";};?>  >&nbsp;<b>Dependence</b>
 155         <img src="../../../images/space.gif" width="5" height="1">
 156         <input type=checkbox name='risk_substance_ur' <?php if ($obj{"risk_substance_ur"} == "on") {echo "checked";};?>  >&nbsp;<b>Unstable remission of abuse</b>
 157         <img src="../../../images/space.gif" width="5" height="1">
 158         <input type=checkbox name='risk_substance_ab' <?php if ($obj{"risk_substance_ab"} == "on") {echo "checked";};?>  >&nbsp;<b>Abuse</b><br>
 159 <br>
 160 <b>Current physical or sexual abuse:</b><br><input type=checkbox name='risk_sexual_na' <?php if ($obj{"risk_sexual_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
 161         <img src="../../../images/space.gif" width="5" height="1">
 162         <input type=checkbox name='risk_sexual_y' <?php if ($obj{"risk_sexual_y"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
 163         <img src="../../../images/space.gif" width="5" height="1">
 164         <input type=checkbox name='risk_sexual_n' <?php if ($obj{"risk_sexual_n"} == "on") {echo "checked";};?>>&nbsp;<b>No</b><br>
 165         <b>Legally reportable?</b>&nbsp;<input type=checkbox name='risk_sexual_ry' <?php if ($obj{"risk_sexual_ry"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
 166         <img src="../../../images/space.gif" width="5" height="1">
 167         <input type=checkbox name='risk_sexual_rn' <?php if ($obj{"risk_sexual_rn"} == "on") {echo "checked";};?>>&nbsp;<b>No</b>
 168         <img src="../../../images/space.gif" width="5" height="1">
 169         <b>If yes, client is </b>&nbsp;<input type=checkbox name='risk_sexual_cv' <?php if ($obj{"risk_sexual_cv"} == "on") {echo "checked";};?>>&nbsp;<b>victum</b>
 170         &nbsp;<input type=checkbox name='risk_sexual_cp' <?php if ($obj{"risk_sexual_cp"} == "on") {echo "checked";};?>>&nbsp;<b>perpetrator</b><br>
 171         <input type=checkbox name='risk_sexual_b' <?php if ($obj{"risk_sexual_b"} == "on") {echo "checked";};?>>&nbsp;<b>Both</b>&nbsp;
 172         <img src="../../../images/space.gif" width="5" height="1">
 173         <input type=checkbox name='risk_sexual_nf' <?php if ($obj{"risk_sexual_nf"} == "on") {echo "checked";};?>>&nbsp;<b>neither, but abuse exists in family</b>&nbsp;<br>
 174 <br>
 175 <b>Current child/elder abuse:</b><br><input type=checkbox name='risk_neglect_na' <?php if ($obj{"risk_neglect_na"} == "on") {echo "checked";};?>  >&nbsp;<b>Not Assessed</b>
 176         <img src="../../../images/space.gif" width="5" height="1">
 177         <input type=checkbox name='risk_neglect_y' <?php if ($obj{"risk_neglect_y"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
 178         <img src="../../../images/space.gif" width="5" height="1">
 179         <input type=checkbox name='risk_neglect_n' <?php if ($obj{"risk_neglect_n"} == "on") {echo "checked";};?>>&nbsp;<b>No</b><br>
 180         <b>Legally reportable?</b>&nbsp;<input type=checkbox name='risk_neglect_ry' <?php if ($obj{"risk_neglect_ry"} == "on") {echo "checked";};?>>&nbsp;<b>Yes</b>
 181         <img src="../../../images/space.gif" width="5" height="1">
 182         <input type=checkbox name='risk_neglect_rn' <?php if ($obj{"risk_neglect_rn"} == "on") {echo "checked";};?>>&nbsp;<b>No</b>
 183         <img src="../../../images/space.gif" width="5" height="1">
 184         <b>If yes, client is </b>&nbsp;<input type=checkbox name='risk_neglect_cv' <?php if ($obj{"risk_neglect_cv"} == "on") {echo "checked";};?>>&nbsp;<b>victum</b>
 185         &nbsp;<input type=checkbox name='risk_neglect_cp' <?php if ($obj{"risk_neglect_cp"} == "on") {echo "checked";};?>>&nbsp;<b>perpetrator</b><br>
 186         <input type=checkbox name='risk_neglect_cb' <?php if ($obj{"risk_neglect_cb"} == "on") {echo "checked";};?>>&nbsp;<b>Both</b>&nbsp;
 187         <img src="../../../images/space.gif" width="5" height="1">
 188         <input type=checkbox name='risk_neglect_cn' <?php if ($obj{"risk_neglect_cn"} == "on") {echo "checked";};?>>&nbsp;<b>neither, but abuse exists in family</b>&nbsp;<br>
 189 <br>
 190
 191         <b>If risk exists:</b>&nbsp;client&nbsp;<input type=checkbox name='risk_exists_c' <?php if ($obj{"risk_exists_c"} == "on") {echo "checked";};?>><b>can</b>&nbsp;
 192         <img src="../../../images/space.gif" width="5" height="1">
 193         <input type=checkbox name='risk_exists_cn' <?php if ($obj{"risk_exists_cn"} == "on") {echo "checked";};?>>&nbsp;<b>cannot</b>&nbsp;
 194         <b>meaningfully agree to a contract not to harm</b><br>
 195         <input type=checkbox name='risk_exists_s' <?php if ($obj{"risk_exists_s"} == "on") {echo "checked";};?>>&nbsp;<b>self</b>
 196         <img src="../../../images/space.gif" width="5" height="1">
 197         <input type=checkbox name='risk_exists_o' <?php if ($obj{"risk_exists_o"} == "on") {echo "checked";};?>>&nbsp;<b>others</b>
 198         <img src="../../../images/space.gif" width="5" height="1">
 199         <input type=checkbox name='risk_exists_b' <?php if ($obj{"risk_exists_b"} == "on") {echo "checked";};?>>&nbsp;<b>both</b><br><br>
 200
 201     <b>Risk to community (criminal):</b><br>
 202     <textarea cols=100 rows=3 wrap=virtual name="risk_community" ><?php echo stripslashes($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 ($obj{"recommendations_psy_i"} == "on") {echo "checked";};?>>&nbsp;<b>Individual</b>
 209         <img src="../../../images/space.gif" width="5" height="1">
 210         <input type=checkbox name='recommendations_psy_f' <?php if ($obj{"recommendations_psy_f"} == "on") {echo "checked";};?>>&nbsp;<b>Family</b>
 211         <img src="../../../images/space.gif" width="5" height="1">
 212         <input type=checkbox name='recommendations_psy_m' <?php if ($obj{"recommendations_psy_m"} == "on") {echo "checked";};?>>&nbsp;<b>Marital/relational</b>
 213         <img src="../../../images/space.gif" width="5" height="1">
 214         <input type=checkbox name='recommendations_psy_o' <?php if ($obj{"recommendations_psy_o"} == "on") {echo "checked";};?>>&nbsp;<b>Other</b><br>
 215     <textarea cols=100 rows=3 wrap=virtual name="recommendations_psy_notes" ><?php echo stripslashes($obj{"recommendations_psy_notes"});?></textarea><br>
 216
 217 <b>Date report sent to referral source:</b>
 218         <img src="../../../images/space.gif" width="5" height="1">
 219         <input type="text" name='refer_date' value="<?php echo stripslashes($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="<?php 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";};?>>&nbsp;<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 ($obj{"support_cs"} == "on") {echo "checked";};?>>&nbsp;<b>Communication skills</b>
 241         <img src="../../../images/space.gif" width="5" height="1">
 242     <input type=checkbox name='support_sm' <?php if ($obj{"support_sm"} == "on") {echo "checked";};?>>&nbsp;<b>Stress management</b><br>
 243
 244         <input type=checkbox name='support_a' <?php if ($obj{"support_a"} == "on") {echo "checked";};?>>&nbsp;<b>Assertiveness</b>
 245         <img src="../../../images/space.gif" width="5" height="1">
 246     <input type=checkbox name='support_o' <?php if ($obj{"support_o"} == "on") {echo "checked";};?>>&nbsp;<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";};?>>&nbsp;<b>Offender program</b>
 252         <img src="../../../images/space.gif" width="5" height="1">
 253     <input type=checkbox name='legal_so' <?php if ($obj{"legal_so"} == "on") {echo "checked";};?>>&nbsp;<b>Sex Offender Groups</b>
 254         <img src="../../../images/space.gif" width="5" height="1">
 255     <input type=checkbox name='legal_sa' <?php if ($obj{"legal_sa"} == "on") {echo "checked";};?>>&nbsp;<b>Substance abuse</b><br>
 256
 257         <input type=checkbox name='legal_ve' <?php if ($obj{"legal_ve"} == "on") {echo "checked";};?>>&nbsp;<b>Victum empathy group</b>
 258         <img src="../../../images/space.gif" width="5" height="1">
 259     <input type=checkbox name='legal_ad' <?php if ($obj{"legal_ad"} == "on") {echo "checked";};?>>&nbsp;<b>Referral to advocate</b>
 260         <img src="../../../images/space.gif" width="5" height="1">
 261     <input type="text" name='legal_adl' value="<?php 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";};?>>&nbsp;<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
 302 formFooter();
 303 ?>