Sync template from atomicqms-style deployment
This commit is contained in:
0
Forms/Assessment-Tools/.gitkeep
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0
Forms/Assessment-Tools/.gitkeep
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64
Forms/FRM-001-Document-Change-Request.md
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64
Forms/FRM-001-Document-Change-Request.md
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# Document Change Request Form
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| Form ID | FRM-001 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: Request Information
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| Field | Entry |
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|-------|-------|
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| Request Date | |
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| Requested By | |
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| Department | |
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## Section 2: Document Information
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| Field | Entry |
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|-------|-------|
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| Document Number | |
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| Document Title | |
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| Current Revision | |
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## Section 3: Change Description
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### Type of Change
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- [ ] New Document
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- [ ] Revision to Existing Document
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- [ ] Document Obsolescence
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### Description of Change
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*(Describe the proposed change in detail)*
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### Reason for Change
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*(Explain why this change is needed)*
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## Section 4: Impact Assessment
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### Affected Areas
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- [ ] Training Required
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- [ ] Other Documents Affected
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- [ ] Process Changes Required
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- [ ] Validation Impact
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### List Affected Documents
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## Section 5: Approvals
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| Requester | | | |
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| Document Owner | | | |
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| Quality Assurance | | | |
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---
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*Form FRM-001 Rev 1.0*
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91
Forms/FRM-003-CAPA-Form.md
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Forms/FRM-003-CAPA-Form.md
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# Corrective and Preventive Action (CAPA) Form
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| Form ID | FRM-003 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: CAPA Identification
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| Field | Entry |
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|-------|-------|
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| CAPA Number | |
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| Date Initiated | |
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| Initiated By | |
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| CAPA Owner | |
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| Target Closure Date | |
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## Section 2: Classification
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### Type
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- [ ] Corrective Action
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- [ ] Preventive Action
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### Source
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- [ ] Customer Complaint
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- [ ] Internal Audit
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- [ ] External Audit
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- [ ] Process Deviation
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- [ ] Nonconforming Product
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- [ ] Management Review
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- [ ] Other: ____________
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### Priority
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- [ ] Critical (5 business days)
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- [ ] Major (15 business days)
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- [ ] Minor (30 business days)
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## Section 3: Problem Description
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*(Describe the nonconformity or potential nonconformity)*
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## Section 4: Immediate Containment
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*(Actions taken to contain the immediate impact)*
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## Section 5: Root Cause Investigation
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### Investigation Method Used
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- [ ] 5 Whys
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- [ ] Fishbone Diagram
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- [ ] Fault Tree Analysis
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- [ ] Other: ____________
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### Root Cause Determination
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## Section 6: Corrective/Preventive Actions
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| Action | Responsible | Due Date | Status |
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|--------|-------------|----------|--------|
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| | | | |
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| | | | |
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| | | | |
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## Section 7: Effectiveness Verification
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| Criteria | Method | Result |
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|----------|--------|--------|
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| | | |
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Verification Date: ____________
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Verified By: ____________
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## Section 8: Closure
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| CAPA Owner | | | |
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| Quality Approval | | | |
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---
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*Form FRM-003 Rev 1.0*
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Forms/FRM-006-Audit-Checklist.md
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Forms/FRM-006-Audit-Checklist.md
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# Internal Audit Checklist
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| Form ID | FRM-006 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Audit Information
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| Field | Entry |
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|-------|-------|
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| Audit Number | |
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| Audit Date | |
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| Area/Process Audited | |
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| Lead Auditor | |
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| Auditee(s) | |
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---
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## Checklist Items
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| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes |
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|---|---------------------|-----------|---------|----------------|
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| 1 | Are current versions of applicable procedures available? | SOP-001 | | |
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| 2 | Are personnel trained on applicable procedures? | SOP-003 | | |
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| 3 | Are training records current and complete? | SOP-003 | | |
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| 4 | Are records properly maintained and retrievable? | SOP-001 | | |
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| 5 | Are nonconformities being documented and addressed? | SOP-002 | | |
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| 6 | Are CAPAs being completed on time? | SOP-002 | | |
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| 7 | Is equipment calibrated and maintained? | | | |
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| 8 | Are process controls being followed? | | | |
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| 9 | Are quality objectives being monitored? | | | |
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| 10 | | | | |
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**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable
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---
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## Findings Summary
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| Finding # | Type | Description | Clause Reference |
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|-----------|------|-------------|------------------|
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| | | | |
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| | | | |
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---
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## Auditor Signature
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| Auditor | Signature | Date |
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|---------|-----------|------|
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| | | |
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---
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*Form FRM-006 Rev 1.0*
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0
Forms/Intake-Forms/.gitkeep
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Forms/Intake-Forms/.gitkeep
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380
Forms/Intake-Forms/FRM-MHO-001-New-Patient-Intake.md
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Forms/Intake-Forms/FRM-MHO-001-New-Patient-Intake.md
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# Mental Health New Patient Intake Form
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| Form ID | FRM-MHO-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Last Name | |
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| First Name | |
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| Preferred Name | |
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| Date of Birth | |
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| Age | |
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| Sex | ☐ Male ☐ Female ☐ Other |
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| Gender Identity | |
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| Pronouns | |
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### Contact Information
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| Field | Entry |
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|-------|-------|
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| Address | |
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| City, State, ZIP | |
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| Home Phone | |
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| Cell Phone | |
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| Email | |
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| Preferred Contact Method | ☐ Home ☐ Cell ☐ Email |
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| OK to Leave Detailed Message? | ☐ Yes ☐ No |
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---
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## Emergency Contact
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| Field | Entry |
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|-------|-------|
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| Name | |
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| Relationship | |
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| Phone | |
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| Address | |
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---
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## Referral Information
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| Field | Entry |
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|-------|-------|
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| Referred By | |
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| Referring Provider Phone | |
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| Primary Care Physician | |
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| PCP Phone/Fax | |
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| Current Therapist (if any) | |
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| Current Prescriber (if any) | |
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---
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## Reason for Seeking Treatment
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**What brings you in for treatment today?**
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**What are your main symptoms or concerns?**
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**When did these symptoms start?**
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**What do you hope to get out of treatment?**
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---
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## Symptom Checklist
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*Check all symptoms you are currently experiencing:*
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### Mood Symptoms
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☐ Depressed mood
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☐ Loss of interest/pleasure
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☐ Hopelessness
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☐ Guilt
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☐ Irritability
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☐ Mood swings
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☐ Elevated/euphoric mood
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☐ Decreased need for sleep
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☐ Racing thoughts
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☐ Increased energy
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### Anxiety Symptoms
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☐ Excessive worry
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☐ Restlessness
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☐ Difficulty concentrating
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☐ Muscle tension
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☐ Sleep problems
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☐ Panic attacks
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☐ Fear of social situations
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☐ Specific phobias
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☐ Obsessive thoughts
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☐ Compulsive behaviors
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### Trauma Symptoms
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☐ Flashbacks/intrusive memories
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☐ Nightmares
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☐ Avoiding reminders of trauma
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☐ Emotional numbness
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☐ Hypervigilance
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☐ Easily startled
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### Psychotic Symptoms
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☐ Hearing voices
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☐ Seeing things others don't see
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☐ Paranoid thoughts
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☐ Unusual beliefs
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☐ Confused thinking
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### Other Symptoms
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☐ Difficulty concentrating
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☐ Memory problems
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☐ Impulsivity
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☐ Anger problems
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☐ Relationship difficulties
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☐ Work/school problems
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☐ Appetite changes
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☐ Weight changes
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☐ Fatigue/low energy
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☐ Chronic pain
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---
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## Suicidal/Self-Harm History
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| Question | Response |
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|----------|----------|
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| Are you currently having thoughts of suicide? | ☐ Yes ☐ No |
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| Are you currently having thoughts of harming yourself? | ☐ Yes ☐ No |
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| Have you ever attempted suicide? | ☐ Yes ☐ No |
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| If yes, when and how? | |
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| Have you ever engaged in self-harm (cutting, burning, etc.)? | ☐ Yes ☐ No |
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| If yes, describe: | |
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---
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## Psychiatric History
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### Previous Treatment
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| Treatment Type | Yes/No | Where | When | Helpful? |
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|----------------|--------|-------|------|----------|
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| Outpatient therapy | ☐ | | | ☐ Yes ☐ No |
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| Outpatient psychiatry | ☐ | | | ☐ Yes ☐ No |
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| Intensive outpatient (IOP) | ☐ | | | ☐ Yes ☐ No |
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| Partial hospitalization (PHP) | ☐ | | | ☐ Yes ☐ No |
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| Psychiatric hospitalization | ☐ | | | ☐ Yes ☐ No |
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| Residential treatment | ☐ | | | ☐ Yes ☐ No |
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| ECT | ☐ | | | ☐ Yes ☐ No |
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| TMS | ☐ | | | ☐ Yes ☐ No |
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### Previous Diagnoses
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*Check all that you have been diagnosed with:*
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☐ Depression
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☐ Bipolar Disorder
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☐ Anxiety Disorder
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☐ Panic Disorder
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☐ PTSD
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☐ OCD
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☐ ADHD
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☐ Schizophrenia/Schizoaffective
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☐ Personality Disorder (type: _______)
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☐ Eating Disorder
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☐ Substance Use Disorder
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☐ Autism Spectrum Disorder
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☐ Other: _______________
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---
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## Current Medications
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| Medication | Dose | Frequency | Prescriber |
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|------------|------|-----------|------------|
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| | | | |
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| | | | |
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| | | | |
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| | | | |
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| | | | |
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### Past Psychiatric Medications
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*List medications you have tried in the past:*
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| Medication | Helpful? | Side Effects? | Reason Stopped |
|
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|------------|----------|---------------|----------------|
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| | ☐ Yes ☐ No | | |
|
||||
| | ☐ Yes ☐ No | | |
|
||||
| | ☐ Yes ☐ No | | |
|
||||
| | ☐ Yes ☐ No | | |
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---
|
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|
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## Allergies
|
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☐ No Known Allergies
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|
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| Medication/Substance | Reaction |
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|---------------------|----------|
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| | |
|
||||
| | |
|
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|
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---
|
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|
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## Substance Use History
|
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|
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| Substance | Ever Used | Age First Used | Current Use | Amount/Frequency | Last Used |
|
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|-----------|-----------|----------------|-------------|------------------|-----------|
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| Alcohol | ☐ | | ☐ | | |
|
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| Marijuana/Cannabis | ☐ | | ☐ | | |
|
||||
| Cocaine/Crack | ☐ | | ☐ | | |
|
||||
| Heroin/Opioids | ☐ | | ☐ | | |
|
||||
| Methamphetamine | ☐ | | ☐ | | |
|
||||
| Benzodiazepines (non-Rx) | ☐ | | ☐ | | |
|
||||
| Tobacco/Nicotine | ☐ | | ☐ | | |
|
||||
| Other: | ☐ | | ☐ | | |
|
||||
|
||||
**Have you ever had treatment for substance use?** ☐ Yes ☐ No
|
||||
|
||||
If yes, describe:
|
||||
|
||||
---
|
||||
|
||||
## Medical History
|
||||
|
||||
### Current Medical Conditions
|
||||
|
||||
☐ None
|
||||
|
||||
| Condition | Notes |
|
||||
|-----------|-------|
|
||||
| | |
|
||||
| | |
|
||||
| | |
|
||||
|
||||
### Past Surgeries/Hospitalizations
|
||||
|
||||
| Surgery/Hospitalization | Year |
|
||||
|------------------------|------|
|
||||
| | |
|
||||
| | |
|
||||
|
||||
### For Women
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Are you pregnant? | ☐ Yes ☐ No ☐ Maybe |
|
||||
| Are you breastfeeding? | ☐ Yes ☐ No |
|
||||
| Last menstrual period | |
|
||||
| Using contraception? | ☐ Yes ☐ No |
|
||||
|
||||
---
|
||||
|
||||
## Family Psychiatric History
|
||||
|
||||
*Check all that apply to biological relatives:*
|
||||
|
||||
| Condition | Mother | Father | Sibling | Grandparent | Other |
|
||||
|-----------|--------|--------|---------|-------------|-------|
|
||||
| Depression | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| Bipolar Disorder | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| Anxiety | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| Schizophrenia | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| Substance Abuse | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| Suicide/Attempt | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| ADHD | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
| Other: | ☐ | ☐ | ☐ | ☐ | ☐ |
|
||||
|
||||
---
|
||||
|
||||
## Social History
|
||||
|
||||
### Living Situation
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Who do you live with? | |
|
||||
| Type of housing | ☐ Own ☐ Rent ☐ With family ☐ Homeless ☐ Other |
|
||||
| Housing stability | ☐ Stable ☐ At risk ☐ Unstable |
|
||||
|
||||
### Relationships
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Marital/Relationship status | ☐ Single ☐ Married ☐ Partnered ☐ Divorced ☐ Widowed |
|
||||
| Children (ages) | |
|
||||
| Quality of relationships | ☐ Good ☐ Fair ☐ Poor |
|
||||
| Social support | ☐ Strong ☐ Some ☐ Limited ☐ None |
|
||||
|
||||
### Education/Employment
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Highest education | |
|
||||
| Current employment | ☐ Full-time ☐ Part-time ☐ Unemployed ☐ Disabled ☐ Retired ☐ Student |
|
||||
| Occupation | |
|
||||
| Work/school problems? | ☐ Yes ☐ No |
|
||||
|
||||
### Legal
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Current legal issues? | ☐ Yes ☐ No |
|
||||
| If yes, describe: | |
|
||||
| History of incarceration? | ☐ Yes ☐ No |
|
||||
|
||||
### Trauma History
|
||||
|
||||
*Have you experienced any of the following?*
|
||||
|
||||
☐ Physical abuse
|
||||
☐ Sexual abuse
|
||||
☐ Emotional/verbal abuse
|
||||
☐ Neglect
|
||||
☐ Domestic violence
|
||||
☐ Witnessed violence
|
||||
☐ Military combat
|
||||
☐ Serious accident
|
||||
☐ Natural disaster
|
||||
☐ Other trauma: _______________
|
||||
|
||||
---
|
||||
|
||||
## Current Stressors
|
||||
|
||||
*Rate your current stress level (1-10):* _____
|
||||
|
||||
*What are your main stressors right now?*
|
||||
|
||||
---
|
||||
|
||||
## Strengths and Supports
|
||||
|
||||
*What are your strengths?*
|
||||
|
||||
*Who are your supports (family, friends, community)?*
|
||||
|
||||
*What coping strategies do you currently use?*
|
||||
|
||||
---
|
||||
|
||||
## Goals for Treatment
|
||||
|
||||
*What would you like to accomplish through treatment?*
|
||||
|
||||
1.
|
||||
2.
|
||||
3.
|
||||
|
||||
---
|
||||
|
||||
## Signature
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Patient Signature | |
|
||||
| Date | |
|
||||
| Guardian Signature (if minor) | |
|
||||
| Relationship to Patient | |
|
||||
|
||||
---
|
||||
|
||||
## For Office Use
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Date Received | |
|
||||
| Entered By | |
|
||||
| Appointment Date | |
|
||||
| Assigned Provider | |
|
||||
| Notes | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-MHO-001 Rev 1.0 - Mental Health New Patient Intake Form*
|
||||
0
Forms/Progress-Notes/.gitkeep
Normal file
0
Forms/Progress-Notes/.gitkeep
Normal file
0
Forms/Safety-Plans/.gitkeep
Normal file
0
Forms/Safety-Plans/.gitkeep
Normal file
72
Forms/Training/FRM-004-Training-Record.md
Normal file
72
Forms/Training/FRM-004-Training-Record.md
Normal file
@@ -0,0 +1,72 @@
|
||||
# Training Record Form
|
||||
|
||||
| Form ID | FRM-004 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Employee Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Employee Name | |
|
||||
| Employee ID | |
|
||||
| Department | |
|
||||
| Job Title | |
|
||||
|
||||
## Section 2: Training Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Training Title | |
|
||||
| Training Date | |
|
||||
| Training Duration | |
|
||||
| Trainer Name | |
|
||||
| Trainer Qualification | |
|
||||
|
||||
### Training Type
|
||||
- [ ] Initial Training
|
||||
- [ ] Retraining
|
||||
- [ ] Refresher
|
||||
- [ ] Procedure Update
|
||||
|
||||
### Delivery Method
|
||||
- [ ] Classroom
|
||||
- [ ] On-the-Job
|
||||
- [ ] Self-Study
|
||||
- [ ] Computer-Based
|
||||
- [ ] Other: ____________
|
||||
|
||||
## Section 3: Training Content
|
||||
|
||||
*(List topics covered or attach training materials)*
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 4: Assessment
|
||||
|
||||
### Assessment Method
|
||||
- [ ] Written Test
|
||||
- [ ] Practical Demonstration
|
||||
- [ ] Verbal Assessment
|
||||
- [ ] Observation
|
||||
|
||||
### Assessment Results
|
||||
|
||||
| Metric | Result |
|
||||
|--------|--------|
|
||||
| Score (if applicable) | |
|
||||
| Pass/Fail | |
|
||||
|
||||
## Section 5: Signatures
|
||||
|
||||
| Role | Name | Signature | Date |
|
||||
|------|------|-----------|------|
|
||||
| Trainee | | | |
|
||||
| Trainer | | | |
|
||||
| Supervisor | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-004 Rev 1.0*
|
||||
0
Forms/Treatment-Plans/.gitkeep
Normal file
0
Forms/Treatment-Plans/.gitkeep
Normal file
Reference in New Lab Ticket
Block a user