AHP Initial Rpt to GP

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					                                                   SUTHERLAND ACCESS TO ALLIED PSYCHOLOGICAL SERVICES (ATAPS) PROGRAM


                Tier One ATAPS: Initial Report to GP from AHP
                         Allied Health Provider to complete and send report to referring GP after initial ATAPS session.

Patient information:
Patient name:                                                             DOB:            /         /
Patient UI#:                                                              Referring GP:
Date of first session:             /       /

Initial Session Information

Outcome tool:                           Tool used:                                Score(s):


Initial assessment findings
(including comorbidity, if any):




Results and interpretation of
standard measures:




Presenting problem:




Background/history of
presenting problem:




Problem formulation:




Suggested treatment plan:


Recommendation for future
appointments with ATAPS                   Yes             No
AHP:

If no, recommendation for
alternative treatment or
referral:


Details of ATAPS Allied Health Provider:
Name:
Telephone:
Fax:

The above information is a true and accurate record of services provided by me:


Signed: ……………………………………………………………….… Date:                                                        /       /
                                                                                                                           Shire GPs August 2011

				
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posted:9/18/2012
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