Focus Area List

FOCUS AREAS IDENTIFIED DURING INTAKE ASSESSMENT   

Assessment (IE) Date: [date default="02-21-2024"]       

[checkbox name="1f" value="" memo="Living Arrangements/Housing"][conditional field="1f" condition="(1f).is('')"]
Living Arrangements/Housing
Status: [select name="1s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="1s" condition="(1s).is('Treat')"] 
Issues to address: [text name="1t"][/conditional][conditional field="1s" condition="(1s).is('Defer')"]; treat under [text name="1d" memo="enter treatable focus area"][/conditional][conditional field="1s" condition="(1s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="1s" condition="(1s).is('Refer')"] to [text name="1r" memo="enter program/resource"][/conditional] [conditional field="1s" condition="(1s).is('Withdraw')"]
Reason for withdrawal: [text    name="1w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="1df" value="" memo="Language/Accomodations"][conditional field="1df" condition="(1df).is('')"]
Language/Special Accomodations/Needs
Issues to address: [text name=""][/conditional]
[checkbox name="2f" value="" memo="Mental Health"][conditional field="2f" condition="(2f).is('')"]
Mental Health
Status: [select name="2s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="2s" condition="(2s).is('Treat')"] 
Dx(s), Sx(s) or issues to address: [text name="2t"][/conditional][conditional field="2s" condition="(2s).is('Defer')"]; treat under [text name="2d" memo="enter treatable focus area"][/conditional][conditional field="2s" condition="(2s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="2s" condition="(2s).is('Refer')"] to [text name="2r" memo="enter program/resource"][/conditional] [conditional field="2s" condition="(2s).is('Withdraw')"]
Reason for withdrawal: [text    name="2w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="3f" value="" memo="SI/HI"][conditional field="3f" condition="(3f).is('')"]
Suicidal/Homicidal Ideation
Status: [select name="3s" value="Defer|Monitor|Refer|Treat"][conditional field="3s" condition="(3s).is('Treat')"] 
Issues to address: [text name="3t"]
[checkbox value="Initial safety plan completed."][/conditional][conditional field="3s" condition="(3s).is('Defer')"]; treat under [text name="3d" memo="enter treatable focus area"]
[checkbox value="Initial safety plan completed."][/conditional][conditional field="3s" condition="(3s).is('Monitor')"]
[checkbox value="Initial safety plan completed."][/conditional][conditional field="3s" condition="(3s).is('Refer')"] to [text name="3r" memo="enter program/resource"]
[checkbox value="Initial safety plan completed."][/conditional][/conditional]
[checkbox name="4f" value="" memo="Death/Dying"][conditional field="4f" condition="(4f).is('')"]
Death/Dying
Status: [select name="4s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="4s" condition="(4s).is('Treat')"] 
Issues to address: [text name="4t"][/conditional][conditional field="4s" condition="(4s).is('Defer')"]; treat under [text name="4d" memo="enter treatable focus area"][/conditional][conditional field="4s" condition="(4s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="4s" condition="(4s).is('Refer')"] to [text name="4r" memo="enter program/resource"][/conditional] [conditional field="4s" condition="(4s).is('Withdraw')"]
Reason for withdrawal: [text    name="4w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="5f" value="" memo="Alcohol/Drug"][conditional field="5f" condition="(5f).is('')"]
Alcohol/Drug History
Status: [select name="5s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="5s" condition="(5s).is('Treat')"] 
Dx(s), Sx(s) or issues to address: [text name="5t"][/conditional][conditional field="5s" condition="(5s).is('Defer')"]; treat under [text name="5d" memo="enter treatable focus area"][/conditional][conditional field="5s" condition="(5s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="5s" condition="(5s).is('Refer')"] to [text name="5r" memo="enter program/resource"][/conditional] [conditional field="5s" condition="(5s).is('Withdraw')"]
Reason for withdrawal: [text    name="5w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="6f" value="" memo="Abuse"][conditional field="6f" condition="(6f).is('')"]
Abuse History
Status: [select name="6s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="6s" condition="(6s).is('Treat')"] 
Dx(s), Sx(s) or issues to address: [text name="6t"][/conditional][conditional field="6s" condition="(6s).is('Defer')"]; treat under [text name="6d" memo="enter treatable focus area"][/conditional][conditional field="6s" condition="(6s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="6s" condition="(6s).is('Refer')"] to [text name="6r" memo="enter program/resource"][/conditional] [conditional field="6s" condition="(6s).is('Withdraw')"]
Reason for withdrawal: [text    name="6w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="7f" value="" memo="HIV Health"][conditional field="7f" condition="(7f).is('')"]
HIV Health History
Status: [select name="7s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="7s" condition="(7s).is('Treat')"] 
Issues to address: [text name="7t"][/conditional][conditional field="7s" condition="(7s).is('Defer')"]; treat under [text name="7d" memo="enter treatable focus area"][/conditional][conditional field="7s" condition="(7s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="7s" condition="(7s).is('Refer')"] to [text name="7r" memo="enter program/resource"][/conditional] [conditional field="7s" condition="(7s).is('Withdraw')"]
Reason for withdrawal: [text    name="7w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="8f" value="" memo="Sexual Health"][conditional field="8f" condition="(8f).is('')"]
Sexual Health History
Status: [select name="8s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="8s" condition="(8s).is('Treat')"] 
Issues to address: [text name="8t"][/conditional][conditional field="8s" condition="(8s).is('Defer')"]; treat under [text name="8d" memo="enter treatable focus area"][/conditional][conditional field="8s" condition="(8s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="8s" condition="(8s).is('Refer')"] to [text name="8r" memo="enter program/resource"][/conditional] [conditional field="8s" condition="(8s).is('Withdraw')"]
Reason for withdrawal: [text    name="8w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="9f" value="" memo="Orientation/Gender"][conditional field="9f" condition="(9f).is('')"]
Sexual Orientation and Gender Identity History
Status: [select name="9s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="9s" condition="(9s).is('Treat')"] 
Issues to address: [text name="9t"][/conditional][conditional field="9s" condition="(9s).is('Defer')"]; treat under [text name="9d" memo="enter treatable focus area"][/conditional][conditional field="9s" condition="(9s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="9s" condition="(9s).is('Refer')"] to [text name="9r" memo="enter program/resource"][/conditional] [conditional field="9s" condition="(9s).is('Withdraw')"]
Reason for withdrawal: [text    name="9w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="10f" value="" memo="Relationships"][conditional field="10f" condition="(10f).is('')"]
Relationship History
Status: [select name="10s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="10s" condition="(10s).is('Treat')"] 
Issues to address: [text name="10t"][/conditional][conditional field="10s" condition="(10s).is('Defer')"]; treat under [text name="10d" memo="enter treatable focus area"][/conditional][conditional field="10s" condition="(10s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="10s" condition="(10s).is('Refer')"] to [text name="10r" memo="enter program/resource"][/conditional] [conditional field="10s" condition="(10s).is('Withdraw')"]
Reason for withdrawal: [text    name="10w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="10af" value="" memo="Family Involvement"][conditional field="10af" condition="(10af).is('')"]
Family Involvement   
Status: [select name="10as" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="10as" condition="(10as).is('Treat')"] 
Issues to address: [text name="10at"][/conditional][conditional field="10as" condition="(10as).is('Defer')"]; treat under [text name="10ad" memo="enter treatable focus area"][/conditional][conditional field="10as" condition="(10as).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="10as" condition="(10as).is('Refer')"] to [text name="10ar" memo="enter program/resource"][/conditional] [conditional field="10as" condition="(10as).is('Withdraw')"]
Reason for withdrawal: [text    name="10aw"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="11f" value="" memo="Family/Childhood"][conditional field="11f" condition="(11f).is('')"]
Family/Childhood Relationship History
Status: [select name="11s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="11s" condition="(11s).is('Treat')"] 
Issues to address: [text name="11t"][/conditional][conditional field="11s" condition="(11s).is('Defer')"]; treat under [text name="11d" memo="enter treatable focus area"][/conditional][conditional field="11s" condition="(11s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="11s" condition="(11s).is('Refer')"] to [text name="11r" memo="enter program/resource"][/conditional] [conditional field="11s" condition="(11s).is('Withdraw')"]
Reason for withdrawal: [text    name="11w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="12f" value="" memo="Cultural/Religious/Spiritual"][conditional field="12f" condition="(12f).is('')"]
Cultural/Religious/Spiritual History
Status: [select name="12s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="12s" condition="(12s).is('Treat')"] 
Issues to address: [text name="12t"][/conditional][conditional field="12s" condition="(12s).is('Defer')"]; treat under [text name="12d" memo="enter treatable focus area"][/conditional][conditional field="12s" condition="(12s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="12s" condition="(12s).is('Refer')"] to [text name="12r" memo="enter program/resource"][/conditional] [conditional field="12s" condition="(12s).is('Withdraw')"]
Reason for withdrawal: [text    name="12w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="13f" value="" memo="Social/Leisure/Support"][conditional field="13f" condition="(13f).is('')"]
Social/Leisure/Support Network
Status: [select name="13s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="13s" condition="(13s).is('Treat')"] 
Issues to address: [text name="13t"][/conditional][conditional field="13s" condition="(13s).is('Defer')"]; treat under [text name="13d" memo="enter treatable focus area"][/conditional][conditional field="13s" condition="(13s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="13s" condition="(13s).is('Refer')"] to [text name="13r" memo="enter program/resource"][/conditional] [conditional field="13s" condition="(13s).is('Withdraw')"]
Reason for withdrawal: [text    name="13w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="14f" value="" memo="Legal"][conditional field="14f" condition="(14f).is('')"]
Legal History
Status: [select name="14s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="14s" condition="(14s).is('Treat')"] 
Issues to address: [text name="14t"][/conditional][conditional field="14s" condition="(14s).is('Defer')"]; treat under [text name="14d" memo="enter treatable focus area"][/conditional][conditional field="14s" condition="(14s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="14s" condition="(14s).is('Refer')"] to [text name="14r" memo="enter program/resource"][/conditional] [conditional field="14s" condition="(14s).is('Withdraw')"]
Reason for withdrawal: [text    name="14w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="15f" value="" memo="Medical"][conditional field="15f" condition="(15f).is('')"]
Medical History
Status: [select name="15s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="15s" condition="(15s).is('Treat')"] 
Issues to address: [text name="15t"][/conditional][conditional field="15s" condition="(15s).is('Defer')"]; treat under [text name="15d" memo="enter treatable focus area"][/conditional][conditional field="15s" condition="(15s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="15s" condition="(15s).is('Refer')"] to [text name="15r" memo="enter program/resource"][/conditional] [conditional field="15s" condition="(15s).is('Withdraw')"]
Reason for withdrawal: [text    name="15aw"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="15af" value="" memo="Nutrition"][conditional field="15af" condition="(15af).is('')"]
Nutrition Screen
Status: [select name="15as" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="15as" condition="(15as).is('Treat')"] 
Sx(s), conditions or issues to address: [text name="15at"][/conditional][conditional field="15as" condition="(15as).is('Defer')"]; treat under [text name="15ad" memo="enter treatable focus area"][/conditional][conditional field="15as" condition="(15as).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="15as" condition="(15as).is('Refer')"] to [text name="15ar" memo="enter program/resource"][/conditional] [conditional field="15as" condition="(15as).is('Withdraw')"]
Reason for withdrawal: [text    name="15aw"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="15bf" value="" memo="Pain"][conditional field="15bf" condition="(15bf).is('')"]
Pain Screen
Status: [select name="15bs" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="15bs" condition="(15bs).is('Treat')"] 
Sx(s) or issues to address: [text name="15bt"][/conditional][conditional field="15bs" condition="(15bs).is('Defer')"]; treat under [text name="15bd" memo="enter treatable focus area"][/conditional][conditional field="15bs" condition="(15bs).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="15bs" condition="(15bs).is('Refer')"] to [text name="15br" memo="enter program/resource"][/conditional] [conditional field="15bs" condition="(15bs).is('Withdraw')"]
Reason for withdrawal: [text    name="15bw"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="15cf" value="" memo="Nicotine"][conditional field="15cf" condition="(15cf).is('')"]
Nicotine Use
Status: [select name="15cs" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="15cs" condition="(15cs).is('Treat')"] 
Dx or issues to address: [text name="15ct"][/conditional][conditional field="15cs" condition="(15cs).is('Defer')"]; treat under [text name="15cd" memo="enter treatable focus area"][/conditional][conditional field="15cs" condition="(15cs).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="15cs" condition="(15cs).is('Refer')"] to [text name="15cr" memo="enter program/resource"][/conditional] [conditional field="15cs" condition="(15cs).is('Withdraw')"]
Reason for withdrawal: [text    name="15cw"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="15df" value="" memo="Wellness"][conditional field="15df" condition="(15df).is('')"]
Wellness Goals
Status: [select name="15ds" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="15ds" condition="(15ds).is('Treat')"] 
Goals: [text name="15dt"][/conditional][conditional field="15ds" condition="(15ds).is('Defer')"]; treat under [text name="15dd" memo="enter treatable focus area"][/conditional][conditional field="15ds" condition="(15ds).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="15ds" condition="(15ds).is('Refer')"] to [text name="15dr" memo="enter program/resource"][/conditional] [conditional field="15ds" condition="(15ds).is('Withdraw')"]
Reason for withdrawal: [text    name="15dw"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="16f" value="" memo="Education"][conditional field="16f" condition="(16f).is('')"]
Education History
Status: [select name="16s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="16s" condition="(16s).is('Treat')"] 
Issues to address: [text name="16t"][/conditional][conditional field="16s" condition="(16s).is('Defer')"]; treat under [text name="16d" memo="enter treatable focus area"][/conditional][conditional field="16s" condition="(16s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="16s" condition="(16s).is('Refer')"] to [text name="16r" memo="enter program/resource"][/conditional] [conditional field="16s" condition="(16s).is('Withdraw')"]
Reason for withdrawal: [text    name="16w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="17f" value="" memo="Education"][conditional field="17f" condition="(17f).is('')"]Employment/Income
Status: [select name="17s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="17s" condition="(17s).is('Treat')"] 
Issues to address: [text name="17t"][/conditional][conditional field="17s" condition="(17s).is('Defer')"]; treat under [text name="17d" memo="enter treatable focus area"][/conditional][conditional field="17s" condition="(17s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="17s" condition="(17s).is('Refer')"] to [text name="17r" memo="enter program/resource"][/conditional] [conditional field="17s" condition="(17s).is('Withdraw')"]
Reason for withdrawal: [text    name="18w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="18f" value="" memo="Military"][conditional field="18f" condition="(18f).is('')"]Military History   
Status: [select name="18s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="18s" condition="(18s).is('Treat')"] 
Issues to address: [text name="18t"][/conditional][conditional field="18s" condition="(18s).is('Defer')"]; treat under [text name="18d" memo="enter treatable focus area"][/conditional][conditional field="18s" condition="(18s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="18s" condition="(18s).is('Refer')"] to [text name="18r" memo="enter program/resource"][/conditional] [conditional field="18s" condition="(18s).is('Withdraw')"]
Reason for withdrawal: [text    name="18w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="19f" value="" memo="Parenthood"][conditional field="19f" condition="(19f).is('')"]Parenthood History
Status: [select name="19s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="19s" condition="(19s).is('Treat')"] 
Issues to address: [text name="19t"][/conditional][conditional field="19s" condition="(19s).is('Defer')"]; treat under [text name="19d" memo="enter treatable focus area"][/conditional][conditional field="19s" condition="(19s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="19s" condition="(19s).is('Refer')"] to [text name="19r" memo="enter program/resource"][/conditional] [conditional field="19s" condition="(19s).is('Withdraw')"]
Reason for withdrawal: [text    name="19w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
[checkbox name="20f" value="" memo="Self Assessment"][conditional field="20f" condition="(20f).is('')"]Self Assessment/Expectations
Status: [select name="20s" value="Case Manage|Defer|Educate|Monitor|Refer|Treat|Withdraw"][conditional field="20s" condition="(20s).is('Treat')"] 
Issues to address: [text name="20t"][/conditional][conditional field="20s" condition="(20s).is('Defer')"]; treat under [text name="20d" memo="enter treatable focus area"][/conditional][conditional field="20s" condition="(20s).is('Monitor')"]; address barriers as indicated[/conditional][conditional field="20s" condition="(20s).is('Refer')"] to [text name="20r" memo="enter program/resource"][/conditional] [conditional field="20s" condition="(20s).is('Withdraw')"]
Reason for withdrawal: [text    name="20w"][checkbox value=" Ct does not wish to address."][/conditional][/conditional]
Signed by /s/[text default="" memo="Full Name"], [text default="" memo="Credentials"]  

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[comment memo="INSRUCTIONS:
1. Enter    data    and    click    'Caculate    the    Result!'
2. Copy/paste    into    Continuum    NOTE    encounter,    remove    unwanted    spaces.
3. Under    Notes    tab,    type:    FOCUS    AREA    LIST"]