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Dob
AuthorizerName
PresenceinTreatment1
AddressCityState
MedicalHistoryandPhysicalExamination1
NameofPerson
DiagnosticSummary1
DiagnosisBriefDescription1
TeacherProgressNotes
FamilyMentor
1Year
AuthorizationOther
AllowInsurers
AdmissionsProfile
FosterFamily
PresenceinTreatment2
IEP
SchoolRecords/Grades2
inputLineOther2:
EmploymentReleaseField
PsychologicalEvaluation
DischargeSummariesContinuingCarePlan
CaseworkerCitrusFamilyNetwork
MultiDisciplinary2
DiagnosisBriefDescription2
HealthRecords2
MedicalHistoryandPhysicalExamination2
DiagnosticSummary2
inputLineOther1:
MultiDisciplinary1
SchoolRecords/Grades1
HealthRecords1
Client/ResidentName
Staff Print Name
Date
Client or Guardian Print Name
Date
Staff Signature
Clear
Client or Guardian Signature
Clear
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Parent Signature
Clear
Participant Signature
Clear
StudentPortalParticipantName
StudentPortalParticipantSchool
StudentPortalParticipantGrade
StudentPortalStudentID
StudentPortalPassword
StudentPortalCheckboxYes
StudentPortalCheckboxNo
StudentPortalPublicSchoolCheckboxYes
StudentPortalPublicSchoolCheckboxNo
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