Remote Chat Log 2019v1

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Question - Not Required - The contact is reaching out for

   


 


 


 


 
Question - Not Required - Ethnicity of person affected

 


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Question - Not Required - Presenting ED issues

   


 
Question - Not Required - ED diagnosis

   


 
Question - Not Required - Co-occurring issues

 
Question - Not Required - Directed contact to

   


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Question - Not Required - Level of care requested

 
Question - Not Required - If outpatient, discipline requested

   


 
Question - Not Required - Insurance requested

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Question - Not Required - What was requested

   


 


 

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   Please leave this field empty