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PLACE : FAMILY SUPPORT UNIT / FAMILY SUPPORT CLINIC / SNEHATHEEPAM / KOINONIA / OTHERS (SPECIFY)
............................................................................................................................................................................................................................................ TYPE : MENTAL HEALTH / CHILD PROTECTION / GENDER BASED VIOLENCE / ALCOHOL REHABILITATION FAMILY SUPPORT / OTHERS ....................................................................................... SESSION NUMBER : ..........

1. Complaints and problems / Kiwg;ghLfSk; gpur;ridfSk;:

2. Background (context) of the problems / gpur;rpid rk;ge;jkhd gpd;dzp:

3. Things in which the Client is doing well /cjtp NfhUgth; vt;thwhd tplaq;fspy; rpwg;ghf nraw;gLfpwhH:

4. Resources that are available to the Client / cjtp NfhUgtUf;F fpilf;ff;$ba tsq;fs;:

5. First plan of action (steps that could be taken by the Client and/or the Counselor) / KjyhtJ nraw;ghl;bd; jpl;lk; (cjtp NfhUgth; my;yJ Mw;WgLj;Jdh; my;yJ ,UtUk; NrHe;J vLf;ff;$ba eltbf;iffs;):

6. Complains or signs of improvement discussed or observable during this interview / Kiwg;ghLfs; Neh;fhzypd;NghJ fye;Jiuahlg;gl;l my;yJ fhzg;gl;l Kd;Ndw;w mwpFwpfs;:

Date of Assessment: . Time : am/ pm to ..am / pm

FOR THE USE OF MULTIDISCIPLINARY DISTRICT MENTAL HEALTH TEAM - BATTICALOA

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7. Other important new information / Vida Kf;fpa Gjpa tpguq;fs;:

8. Course of the interview: how it started, how it ended , and what happened in between / Neh;fhzypd; nraw;ghl;Lg; gbKiwfs;:vg;gb Muk;gpf;fg;gl;lJ vg;gb KbTw;wJ ,uz;bw;Fk; ,ilapy; eilngw;wJ vd;d.

9. Summary of the problem as it is today (compare with report of the foregoing) / ,d;iwa epiyapy; gpur;rpidapd; RUf;fk; (nrd;w Neh;fhzy; mwpf;ifAld; Xg;gplTk;): gpur;rpidfspd; ,d;iwa epiy

10. Changes in or additions to the plan of action / nraw;ghl;bd; jp;l;lj;jpd; khw;wq;fs; my;yJ Gjpjhf Nrh;f;fg;gl;lit:

11. Any other NtW VjhtJ

Referrals and date of referrals OFFICER 1 2 3 4 5

REASON

DATE OF REFERRAL

Clients Signature(s) .. ...................................................................... Counsellors Name :- Signature : . Date of review :.

Date of Assessment: . Time : am/ pm to ..am / pm

FOR THE USE OF MULTIDISCIPLINARY DISTRICT MENTAL HEALTH TEAM - BATTICALOA

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