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PATIENT AND CLINIC INFORMATION

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Primary Care Provider
Mental Health Provider

THERAPY OPTIONS

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PATIENT DEPRESSION HISTORY

Suicidal Ideations Present?
Yes
No
Has the patient attempted suicide in the past?
Yes
No
Is the patient currently taking anti-depressants?
Yes
No
Have the medications been effective in reducing depression symptoms?
Yes
No
If the patient is not currently taking any anti-depressants, have they taken them before?
Yes
No
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