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RELAPSE FORM COLT Recipient ID: MCC Use Only COLT Name Code: Date Rec d.: Center Code: 1. What is the patient s primary diagnosis? 3 CML S 2. Have immature hematopoietic cells been documented in the

How to fill out relapse form

How to fill out a relapse form?

1. Start by entering your personal information, such as your name, address, and contact details.
2. Provide details about the relapse, including the date it occurred, the specific circumstances surrounding it, and any triggering factors that might have contributed to it.
3. Describe any symptoms or changes in behavior that accompanied the relapse. Be as detailed and specific as possible.
4. Include information about any medications or treatments you were undergoing at the time of the relapse. Mention any changes in medication or dosage that might have coincided with the relapse.
5. If applicable, provide information about any therapy or support groups you were participating in prior to the relapse. State whether you were actively attending or if there were any disruptions in your treatment plan.
6. Indicate whether you sought immediate help or intervention during the relapse and what steps you took to manage the situation.
7. Finally, sign and date the form to acknowledge that the information provided is accurate and complete.

Who needs a relapse form?

1. Individuals undergoing recovery from addiction or substance abuse may need a relapse form to document and track their progress.
2. Mental health professionals, such as therapists, counselors, or psychiatrists, may require their clients to fill out a relapse form to better understand the reasons behind the relapse and tailor their treatment accordingly.
3. Treatment facilities or programs, including rehabilitation centers or outpatient clinics, may use relapse forms to assess the effectiveness of their interventions and develop personalized relapse prevention strategies for their patients.

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