Intake Form Psychotherapy by nea34503

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									                                                                   ca44c64f-90c1-43a5-80ca-001dc51da5f2.xls




Item #     InForm Form       Type of Change                                    Requested Action Revision
          Screen and Visit      Explained
            Description
  1      System Screening New Question            4. Has this child been seen at another NCTSN network center(s) for a previous episode(s)   This question was added to capture at
            Information                           of care?                                                                                   Screening/prior to enrollment whether a child
                                                  No                                                                                         has been seen at another NCTSN network
                                                  Yes => If Yes: Was this child enrolled in the NCTSN’s Core Data Set ?                      center.
                                                                    No
                                                                    Yes => If Yes: STOP and call NCTSN @ (919) 668-
                                                                                    8182 for further instructions!


  2      System Screening New Question            5. Has this child been seen at this center for a previous episode(s) of care?              This question removed from DEMO as
            Information                           No                                                                                         Question # 2 and added to System
                                                  Yes => If Yes: Was this child already enrolled in the NCTSN’s Core Data Set?               Screening Information as question #5
                                                           No: Click Submit to continue Enrollment
                                                           Yes => If Yes: STOP, do not proceed with enrollment.
                                                                      If Yes: GO to the Follow-up Assessment and
                                                                              create a Follow up Visit record.

  3           DEMO        All referencesto        Is this child currently participating in the ORC/ MACRO cross-site longitudinal
                          ORC/MACRO are           outcome evaluation?' was revised to ask:
                          changed to Cross-Site   Is this child currently participating in the Cross-Site Evaluation?
                          Evaluation
                          Also for Follow up
                          Information Forms
  4           DEMO        New response            Unknown was added as a response to question 9: Is this child currently
                                                  participating in the Cross-Site Evaluation?
                                                      Unknown
                                                      No
                                                      Yes
  4           DEMO        New Fields added        If the answer to Is this child participating in the Cross-Site Evaluation = Yes,
                                                  answer the new question:
                                                  If Yes: Were all of the standard assessments (CBCL, PTSD-RI &/or TSCC-A)
                                                  completed within the timeframe allowed by the Cross-Site
                                                  Evaluation (30 days from Intake or visit date specified for question 1 above)?
                                                          Yes
                                                          No => If No: Please provide visit date(s) the standard assessments were
                                                  administered.
                                                    NOTE: If assessments were administered over multiple visits, please enter the
                                                  date the assessment was completed.
                                                                   Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Assessment: ______
                                                                            Month     Day         Year
                                                                   Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Assessment: ______
                                                                            Month      Day        Year
                                                                   Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Assessment: ______
                                                                            Month      Day       Year

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Item #      InForm Form           Type of Change                                 Requested Action Revision
          Screen and Visit          Explained
             Description
  5       Brief Intervention New Common Form (Like   Instructions: Brief Intervention refers to the number of sessions that a child/family
         Services Form (BIS) BSLC, will display at   may receive. If a child/family is receiving 3-6 sessions, then complete the following.
                             Baseline and every      1. Is this child receiving brief intervention services?
                             Follow-Up)              No
                                                     Yes => If Yes: Please press the Add Entry button and complete the information for
                                                     EACH episode of care where the child/family receives brief intervention services. A
                                                     new entry is required for each type of treatment and each different set of start/stop
                                                     dates.

                                                     NOTE: A BIS Detail record is expected for each brief episode of care in which the
                                                     child is treated.


  6      BIS DETAIL Record New section               1. What treatment components did the child receive? (Check all that apply)
                                                     Screening
                                                     Assessment
                                                     Case Consultation
                                                     Case Management
                                                     Child and Family Traumatic Stress Intervention (CFTSI)
                                                     Crisis Management
                                                     Referral Services
                                                     Psycho-education
                                                     Safety Planning
                                                     Individual Therapy
                                                     Family Therapy
                                                     Group Therapy
                                                     Support Group
                                                     Other, Specify________

  7      BIS DETAIL Record New section               2. Date the treatment component(s) began: __/__/__


  8      BIS DETAIL Record New section               NOTE: Answer question 3 after the child/family has completed the selected
                                                     treatment component(s).
                                                     3. Did this child/family complete the treatment component(s)?
                                                     No, left treatment before completing => If No: Date left treatment: ___/__/____
                                                     Yes, completed treatment => If Yes: Date completed treatment: __/___/____




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Item #    InForm Form           Type of Change                                     Requested Action Revision
         Screen and Visit         Explained
           Description
 10           BSLC          Added 2 new responses      Two new treatments were added to the response option list, 'Child Parent
                                                       Psychotherapy(CPP) and Child Behavioral Interventions for Trauma in
                                                       Schools(CBITS). Question 1 now reads:
                                                       1. What treatment is this child/family receiving through a therapist participating in a
                                                       breakthrough series or other learning collaborative? ( Check only one)
                                                       Trauma- Focused Cognitive Behavior Therapy (TF-CBT)
                                                       Life Skills/Life Stories
                                                        Supportive Psychosocial Treatment for Adolescents responding to Chronic Stress
                                                       (SPARCS)
                                                       Trauma Adaptive Recovery Group Education and Therapy (TARGET)
                                                       Trauma Systems Therapy (TST)
                                                       Child Parent Psychotherapy (CPP)
                                                       Child Behavioral Interventions for Trauma in Schools (CBITS)
                                                        Other, Specify name of treatment: _________

 11      FOLLOWUPINFO       Revised form instructions. Instructions now read: Follow-Up Assessment(s) should be completed in each of
                                                       the following conditions: 1. Near the end of planned treatment (e.g., approaching
                                                       the last session for a planned discharge, at the time of termination for children who
                                                       indicate they are dropping out, or at the last session before transferring to an out-of
                                                       NCTSN provider)
                                                       2. Every three months (as long as the child remains in treatment) except if the
                                                       child is enrolled in the Cross-Site Evaluation, follow-up assessments will be
                                                       conducted every 3 months for 12 months even if services/treatment ends.
                                                        3. When a child returns to treatment for a new episode of care
                                                       Every child must have a Follow-up Assessment completed with an “End of
                                                       Treatment” status. Some follow-up data is expected to be reported for all cases
                                                       except those “Lost to follow-up”.

 12      FOLLOWUPINFO       Added new follow-up visit Which type of follow-up is being performed?
                            type                      Follow-up for ongoing treatment
                                                      End of treatment
                                                      Reopening case for new episode of care
                                                      Post treatment (Use only for children participating in the Cross-Site Evaluation)
                                                      Other, Specify: _______




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 Item #        InForm Form         Type of Change                                   Requested Action Revision
             Screen and Visit         Explained
                Description
   13       CLINEVAL, CBCL, Changes to Dynamic           Dynamic Forms should display appropriately for each Follow up visit type. For
              PTSD, TSCC-A    Display Forms for each     Follow-up for ongoing treatment: These forms should display (InsDom,
                              Follow-up Visit type.      IndSev,SerRec, TxNCTSN2, TxNCTSN2Con, ClinEval, CBCL, CBCLcon, PTSD,
                                                         TSCC-A)
                                                         For End of Treatment:
                                                         'Complete as planned'; These forms should display (InsDom, IndSev,SerRec,
                                                         TxNCTSN2, TxNCTSN2Con, ClinEval, CBCL, CBCLcon, PTSD, TSCC-A)
                                                         'Child dropped out of treatment for any reason':These forms should display
                                                         (InsDom, IndSev,SerRec, TxNCTSN2, TxNCTSN2Con, ClinEval, CBCL, CBCLcon,
                                                         PTSD, TSCC-A)
                                                         'Case transferred to another clinic or program':These forms should display
                                                         (InsDom, IndSev,SerRec, TxNCTSN2, TxNCTSN2Con, ClinEval, CBCL, CBCLcon,
                                                         PTSD, TSCC-A)
                                                         ' End of Tx: Case is lost to follow up: No forms should display;
                                                         'End of Tx :Other', Specify___ These forms should display (InsDom,
                                                         IndSev,SerRec, TxNCTSN2, TxNCTSN2Con, ClinEval, CBCL, CBCLcon, PTSD,
                                                         TSCC-A)
                                                         Note: BCLC and BIS are common Forms. They display for both Baseline and
                                                         Follow Up regardless of visit type.
13 (Cont)   CLINEVAL, CBCL, Revised: Changes to          Re-opening case for a new episode: These forms should display (InsDom,
             PTSD, TSCC-A   Dynamic Display Forms        IndSev,SerRec, TxNCTSN2, TxNCTSN2Con, ClinEval, CBCL, CBCLcon, PTSD,
                 (Cont)     (cont)                       TSCC-A)
                                                         Post Treatment (Use only for children participating in cross-site evaluation) : These
                                                         forms should display (InsDom, IndSev,SerRec, TxNCTSN2, TxNCTSN2Con,
                                                         ClinEval, CBCL, CBCLcon, PTSD, TSCC-A)
                                                         Other Specify: These forms should display (InsDom, IndSev,SerRec,TxNCTSN2,
                                                         TxNCTSN2Con, ClinEval, CBCL, CBCLcon, PTSD, TSCC-A)

                                                       Note: BCLC and BIS are common Forms & displays for both Baseline and Follow
                                                       Up at all Visit Types.
   14       FOLLOWUPINFO       Add new Question to # 7 7. Is this child currently participating in the Cross-Site Evaluation?
                                                       No => If No: Indicate reason: (Check only one)
                                                               Parent/guardian/child refuse to participate
                                                               Other, Specify: _____

   15       FOLLOWUPINFO       Revised : Add 'Other' as If Yes: Which data point is being collected? (Check only one)
                               a data point             3 Months;
                                                        6 Months;
                                                        9 Months;
                                                        12 Months;
                                                        98. Other, Specify______



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Item #    InForm Form           Type of Change                                  Requested Action Revision
         Screen and Visit         Explained
           Description
 16      FOLLOWUPINFO       Add New question #8 to If Yes was selected in response to question #7 (Is this child currently participating
                            capture assessments and in the Cross-Site Evaluation), were all of the standard assessments (CBCL, PTSD-
                            dates different than DOV RI &/or TSCC-A) completed within the timeframe allowed by the Cross-Site
                                                     Evaluation (2 weeks/14 business days before or after the visit date specified for
                                                     question 1 above)?
                                                       Yes
                                                       No If No: Please provide visit date(s) the standard assessments were
                                                     administered.
                                                     Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Assessment: ______
                                                                Month     Day         Year
                                                     Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Assessment: ______
                                                                Month     Day         Year
                                                     Date: ___ ___ ___ /___ ___ / ___ ___ ___ ___ Assessment: ______
                                                                Month     Day         Year

                                                      NOTE: If assessments administered over multiple dates, enter the date the
                                                      assessment was completed.

 18          DomDet         Dynamic display change    Domestic Environment Details form is now available in each Follow Up
                                                      Assessment when the answer to "What is this child's primary residence?" is Home
                                                      or With relatives or other family.

 19      NCTSNTREAT2        New Form. NCTSN           Question 1 and 2 on the new form (NCTSNTREAT2) have not changed.
                            Treat form was retired.

 20      NCTSNTREAT2             New response         3. In what setting(s) has your agency provided services for this child and/or
                                                      family? (Check all that apply)
                                                      Clinic
                                                      Home
                                                      School
                                                      Day treatment or partial hospitalization                               Other,
                                                      Specify________




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Item #    InForm Form          Type of Change                             Requested Action Revision
         Screen and Visit        Explained
           Description
 21      NCTSNTREAT2        New question.       4. Please indicate all general modalitiesof treatment provided. (Check all that
                                                apply)
                                                Attachment-based therapy
                                                Behavioral therapy
                                                Cognitive therapy
                                                Cognitive behavioral therapy
                                                Day treatment or partial hospitalization
                                                Expressive therapies (Drawing, movement, theater)
                                                Family therapy
                                                Intensive in-home services
                                                Narrative therapy
                                                Parent training
                                                Peer therapy
                                                Pharmacotherapy/medication
                                                Phase-oriented trauma treatment
                                                Play therapy
                                                Psychoanalysis
                                                Psychodynamic psychotherapy
                                                School-based treatment
                                                Social skills training
                                                Solution-focused therapy
                                                Stress management/relaxation training
                                                Supportive therapy
                                                'Wrap around’ services
                                                Other, Specify:_____________________




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Item #     InForm Form           Type of Change                                   Requested Action Revision
          Screen and Visit         Explained
            Description
 22       NCTSNTREAT2        Revised:To remove all    5. Please indicate the primary general modality of treatment . (Check only
                             specific intervention    one)
                             protocols and non-       Attachment-based therapy
                             therapy based            Behavioral therapy
                             interventions            Cognitive therapy
                                                      Cognitive behavioral therapy
                                                      Day treatment or partial hospitalization
                                                      Expressive therapies (Drawing, movement, theater)
                                                      Family therapy
                                                      Intensive in-home services
                                                      Narrative therapy
                                                      Parent training
                                                      Peer therapy
                                                      Pharmacotherapy/medication
                                                      Phase-oriented trauma treatment
                                                      Play therapy
                                                      Psychoanalysis
                                                      Psychodynamic psychotherapy
                                                      School-based treatment
                                                      Social skills training
                                                      Solution-focused therapy
                                                      Stress management/relaxation training
                                                      Supportive therapy
                                                      'Wrap around’ services
                                                      Other, Specified in question 4

 23        NCTSNTREAT        Retire Entire Item # 6   Retire Entire Item # 6 from old NCTSNTREAT form
                                                      Please indicate the techniques or activities you or colleagues at your agency used
                                                      with the child and/or family during the current episode of care? These can have
                                                      been delivered in any of the settings or frameworks previously mentioned.

 24      NCTSNTREAT2Con New Item Response             1. Please indicate all specific intervention protocols provided, if any. Items should
                        options # 1                   ONLY be checked if treating clinician has been formally trained in the specfic
                                                      intervention protocol. (Check all that apply).

                                                      None
                                                      Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse (AF-CBT)
                                                      Adapted Dialectical Behavior Therapy for Special Populations (DBT-SP)
                                                      Attachment, Self-Regulation, and Competence (ARC): A Comprehensive
                                                      Framework for Intervention with Complexly Traumatized Youth
                                                      Child-Parent Psychotherapy (CPP)
                                                      Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)

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 Item #     InForm Form          Type of Change                              Requested Action Revision
           Screen and Visit        Explained
             Description
24 (cont) NCTSNTREAT2Con New Item Response          Combined Parent Child Cognitive-Behavioral Approach for Children & Families At-
                            options # 1 continued   Risk for Child Physical Abuse
                                                    Combined Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Selective
                                                    Serotonin Reuptake Inhibitors (SSRI)
                                                    Culturally Modified Trauma-Focused Treatment (CM-TFT)
                                                    Eye Movement Desensitization and Reprocessing (EMDR)
                                                    Group Treatment for Children Affected by Domestic Violence
                                                    Integrative Treatment of Complex Trauma (ITCT)

24 (cont) NCTSNTREAT2Con New Item Response          Life Skills/Life Stories
                         options # 1 continued      Multimodality Trauma Treatment Trauma-Focused Coping (MMTT)
                                                    Multisystemic Treatment (MST)
                                                    Parent-Child Interaction Therapy (PCIT)
                                                    Real Life Heroes (RLH)
                                                    Safety, Mentoring, Advocacy, Recovery, and Treatment (SMART)
                                                    Sanctuary Model
                                                    Structured Psychotherapy for Adolescents Responding to Chronic Stress
                                                    (SPARCS)
24 (cont) NCTSNTREAT2Con New Item Response          Trauma Affect Regulation: Guidelines for Education and Therapy for Adolescents
                         options #1 cointinued      and Pre-Adolescents (TARGET-A)
                                                    Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
                                                    Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief(TG-
                                                    CBT)
                                                    Trauma-Informed Brief Intervention Services
                                                    Trauma Systems Therapy (TST)
                                                    UCLA Trauma/Grief Program for Adolescents: Component Therapy for Trauma
                                                    and Grief (CTTG)
                                                    Youth Dialectical Behavior Therapy
                                                    Other, Specify: _____________

   25     NCTSNTREAT2Con New Item Response          2. Please indicate the primary specific intervention protocol provided, if any.
                         options # 2                Items should ONLY be checked if treating clinician has been formally trained
                                                    in the specfic intervention protocol. (Check only one).
                                                    None
                                                    Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse (AF-CBT)
                                                    Adapted Dialectical Behavior Therapy for Special Populations (DBT-SP)
                                                    Attachment, Self-Regulation, and Competence (ARC): A Comprehensive
                                                    Framework for Intervention with Complexly Traumatized Youth
                                                    Child-Parent Psychotherapy (CPP)
                                                    Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)
                                                    Combined Parent Child Cognitive-Behavioral Approach for Children & Families At-
                                                    Risk for Child Physical Abuse

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 Item #     InForm Form          Type of Change                              Requested Action Revision
           Screen and Visit        Explained
             Description
25 (cont) NCTSNTREAT2Con New Item Response          Combined Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Selective
                            options # 2(cont)       Serotonin Reuptake Inhibitors (SSRI
                                                    Culturally Modified Trauma-Focused Treatment (CM-TFT)
                                                    Eye Movement Desensitization and Reprocessing (EMDR)
                                                    Group Treatment for Children Affected by Domestic Violence
                                                    Integrative Treatment of Complex Trauma (ITCT)
25 (cont) NCTSNTREAT2Con Add new list of specific   Life Skills/Life Stories
                         intervention protocols     Multimodality Trauma Treatment Trauma-Focused Coping (MMTT)
                         New Item Response          Multisystemic Treatment (MST)
                         options # 2 (cont)         Parent-Child Interaction Therapy (PCIT)
                                                    Real Life Heroes (RLH)
                                                    Safety, Mentoring, Advocacy, Recovery, and Treatment (SMART)
                                                    Sanctuary Model
                                                    Structured Psychotherapy for Adolescents Responding to Chronic Stress
                                                    (SPARCS)
25 (cont) NCTSNTREAT2Con New Item Response          Trauma Affect Regulation: Guidelines for Education and Therapy for Adolescents
                         options # 2 (cont)         and Pre-Adolescents (TARGET-A)
                                                    Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
                                                    Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Grief (TG-
                                                    CBT)
                                                    Trauma-Informed Brief Intervention Services
                                                    Trauma Systems Therapy (TST)
                                                    UCLA Trauma/Grief Program for Adolescents: Component Therapy for Trauma
                                                    and Grief (CTTG)
                                                    Youth Dialectical Behavioral Therapy
                                                    Other, Specified in question 1

   26     NCTSNTREAT2Con New Item #3 Response       3. Please indicate ALL other psychosocial intervention, brief treatment, crisis
                         options check all that     stabilization, educational, auxiliary services or prevention modalities
                         apply                      provided. (Check all that apply).
                                                    Acupuncture
                                                    Advocacy Activities
                                                    Assessment-Based Treatment for Traumatized Children: Trauma Assessment
                                                    Pathway (TAP)
                                                    Case management/case coordination
                                                    Child Adult Relationship Enhancement (CARE)
                                                    Child Development-Community Policing Program (CDCP)
                                                    Community Outreach Program - Esperanza (COPE)
                                                    Competence based auxiliary services
                                                    Debriefing
                                                    Honoring Children, Making Relatives (HC-MR)
                                                    Honoring Children, Mending the Circle (HC-MC)
                                                    Honoring Children, Respectful Ways (HC-RW)
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Item #      InForm Form     Type of Change                                 Requested Action Revision
           Screen and Visit     Explained
             Description
26 cont   NCTSNTREAT2Con New Item #3 cont.        International Family Adult and Child Enhancement Services (IFACES)
                                                  Meditation/Yoga
                                                  Mentoring
                                                  Posttraumatic Stress Management (PTSM)
                                                  Psycho-education
                                                  Psychological First Aid (PFA)
                                                  Safe Harbor Program
                                                  Self-Management/Coaching
                                                  Support groups
                                                  Streetwork Project
                                                  Therapeutic recreational activities including summer camp
                                                  Other, Specify: _________

  27      NCTSNTREAT2Con Re-number old Item # 7   4. Please indicate ALL the types of clinicians/providers from your agency
                         as New Item # 4          who have worked with this child.(Check all that apply)
                                                  Psychologist (Master’s or Ph.D.)
                                                  School psychologist (Not recorded above)
                                                  Psychology trainee/intern
                                                  Social worker (MSW, LCSW)
                                                  School social worker
                                                  Social worker trainee/intern
                                                  Psychiatrist
                                                  Other physician not psychiatrist
                                                  Physician extender: (NP, PA), Advanced practice nurse (MSN, CNS)
                                                  Nurse (RN, LPN)
                                                  Therapist/counselor (Not recorded above)
                                                  Occupational therapist/physical therapist
                                                  Paraprofessional
                                                  Translator/interpreter
                                                  Other, Specify:_________________




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 Item #     InForm Form         Type of Change                                 Requested Action Revision
           Screen and Visit        Explained
             Description
   28     NCTSNTREAT2Con Re-number old question 5. Please indicate the primary lead clinician/provider from your agency who
                            Item #8 as New Item #5 have worked with this child.(Check only one)
                            question               Psychologist (Master’s or Ph.D.)
                                                   School psychologist (Not recorded above)
                                                   Psychology trainee/intern
                                                   Social worker (MSW, LCSW)
                                                   School social worker
                                                   Social worker trainee/intern
                                                   Psychiatrist
                                                   Other physician not psychiatrist
                                                   Physician extender: (NP, PA), Advanced practice nurse (MSN, CNS)
                                                   Nurse (RN, LPN)
                                                   Therapist/counselor (Not recorded above)
                                                   Occupational therapist/physical therapist
                                                   Paraprofessional
                                                   Translator/interpreter
                                                   Other, Specified in question 4

   29                         Revised the wording        For question #1 for each All Trauma Detail Form, Question 1. 'When was this
          Sexual              question #1 for all        trauma revealed/known?' was replaced with
          Maltreatment/Abuse Trauma Detail Forms         ' 1. When was this trauma revealed/known
          Sexual                                         (to the clinician)?'
29 (cont) Assault/Rape
          (All Trauma Detail  Revised the wording of     1. When was this trauma revealed/known (to the clinician)?
          Forms:              question # 1for all
          Trauma Detail,      Trauma Detail Forms
          War/Terroism/Politi con.
   30         Violence inside Revised the wording of
          calTrauma Detail,                               Was this trauma revealed/known at the Baseline Assessment?' has been changed
            School Violence question # 1 to be in sync   to ' When was this trauma revealed/known (to the clinician)? ' and the responses
              (Not reported   with other Trauma Detail   now include:
                elsewhere)    Forms.                     Baseline
                                                         Other, Please provide date:_ _/_ _ _/_ _ _ _




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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           Description




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