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IDENTIFYING DATA Patient s Name TRICARE OUTPATIENT TREATMENT REPORT P. O. Box 551188 Jacksonville Fl 32255-1188 Fax 1-866-811-4422 FILL OUT COMPLETELY TO AVOID DELAYS DOB Sponsor PROVIDER INFORMATION Provider Name Phone Fax DSM-IV TR Diagnosis Axis I -. /. /. Date first seen Date last seen Anticipated of sessions to complete treatment TREATMENT REPORT Current Clinical Information Circle each. Scale 0 None 1 Mild 2 Moderate 3 Severe 4 Extreme Aggression 0 1 2 3 4 Impulsivity Alcohol /Substance...
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