ࡱ> cfby 1'bjbj .n{{kh PP2228>d:?2&jxxxt(<%%%%%%%$(8+Z&E^&x ^&!!!XxR%!%!!$"$x) R$%t&0&$,+f +$+$dd!ddddd&&!ddd&d0@|+dddddddddP p: CRISIS INFORMATION SHEET  PLACE PHOTO ABOVE Name of Provider Agency:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       ( This Provider Agency contracts with the TN Department of Intellectual and Developmental Disabilities (DIDD). DIDD supports people who have intellectual disabilities (previously referred to as mental retardation). This person should be considered vulnerable and at a higher risk of harm/victimization. Name:  FORMTEXT       DOB:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       Does this person have a Conservator?  FORMTEXT    Yes  FORMTEXT    No If yes, name of Conservator:  FORMTEXT       Phone# of Conservator:  FORMTEXT       Emergency contact person:  FORMTEXT       Phone# of emergency contact:  FORMTEXT       Emergency contact s relationship to person:  FORMTEXT       Does this person have a history of elopement or leaving the home unsupervised:  FORMTEXT    Yes  FORMTEXT   0246BLXl  ųtcUcC"jhV h0JB*UphjihV hU jhV hUmHnHujhV hU hV hjhV hUhbh5 h5"h9:[hb5CJaJmHnHu"h9:[h;=5CJaJmHnHuhgmHnHu jhwhhUmHnHu"h;=hb5CJ$aJ$mHnHuh"5CJ$aJ$mHnHu26Z\, n   !4"R##$p%P&&gd9:[gdZoX 0*gdZoX h^h`gda dhgd $da$gd9:[ $ a$gd"    ( * , . 0 : N F H d t z ˴˨~~~~~~~~rjeS"jhV h[W0JB*Uph hs(5hbh5h9:[h5CJaJh5CJaJh9:[h[W5CJaJha5CJaJ jha5CJaJh9:[hb5CJaJ-jhV h0JB*UmHnHphu"jhV h0JB*Uph(jhV h0JB*UphhV h0JB*ph  ˴˰oXN?Nhs(hs(0J5B*phhs(0JB*ph-jhV h;=0JB*UmHnHphu(jhV h;=0JB*UphhV h;=0JB*ph"jhV h;=0JB*Uph hs(5hbh5hs(-jhV h[W0JB*UmHnHphu"jhV h[W0JB*Uph(jShV h[W0JB*UphhV h[W0JB*ph  " $ & 0 2 4 @ D F Z \ ^ h j l n x }hQA=5hbh[W5hIj%h/lh/lB*Uph-jhV hs(0JB*UmHnHphu(jhV hs(0JB*UphhV hs(0JB*ph"jhV hs(0JB*Uphhs(hs(0J5B*phhs(0JB*ph-jhV h0JB*UmHnHphu(j;hV h0JB*UphhV h0JB*ph"jhV h0JB*Uphx    ( D F J L ` b d n p t Ѿ|umh]V hV hWajhV hWaU hs(5hWahWa5 hWahWa jhV h[WUmHnHuj hV h[WU hV h[WjhV h[WUhs( hWa5hbh[W5hjU heUhZoXhbjheUmHnHujheUhejheU hZoX5! (*.Bdfjlƻˉtoj\j hV hWaU hI5 hb>*j; hV hWaU hV hWahWahWa5hWa jhV hbUmHnHuj hV hbU hV hbjhV hbU hs(5 hWa5 hWa>* jhV hWaUmHnHujhV hWaUjQ hV hWaU"  , F ټձټ٫塦圑|kf^fhbhZoX5 hZoX5 jhV hbUmHnHuj hV hbU hV hbjhV hbU hs(5 h(5 hI5hbUjW heUjheUmHnHuj heUhejheUhZoXhbhb5 hWahWaj' hWah/lU$ No If yes, location/places where the person has previously been found include:  FORMTEXT       Does this person have any behaviors that place him/her or others at a high risk of harm:  FORMTEXT    Yes  FORMTEXT    No If yes, behaviors include:  FORMTEXT       Does this person have a mental health diagnosis which would place him/her at a higher risk of harm:  FORMTEXT    Yes  FORMTEXT    No If yes, mental health diagnoses include:  FORMTEXT       Does this person have a medical health diagnosis which would place him/her at a higher risk of harm:  FORMTEXT    Yes  FORMTEXT    No If yes, medical health diagnoses include:  FORMTEXT       Does this person take any medications that would be life sustaining:  FORMTEXT    Yes  FORMTEXT    No If yes, list medications and reasons for use:  FORMTEXT            This document is a free resource provided by DIDD. Its use is not required. Last updated 2012.08.28 !!!!!!!!!!!!!!!!!!!"" 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