{% include '_header.html' %}

Client Face Sheet

Identifying Data
Name: {{ client.fname }} {{ client.lname }} DOB: {{ client.dob }} Alias(es): {{ demos.alias }} Allergies: {{ demos.allergy }}

Address: {{ demos.address }}Apartment: {{ demos.apartment }} City: {{ demos.city }}State: {{ demos.state }}
Postal Code: {{ demos.post_code }} Phone: {{ demos.phone }}Mobile Phone: {{ demos.phone_mobile }} Other Phone: {{ demos.phone_other }}

Sex Assigned At Birth: {{ demos.sex_birth }} Gender Identity: {{ demos.sex_gender }} Sexual Orientation: {{ demos.sex_orientation }}

Race: {{ demos.race }} If African-American: {{ demos.race_detail }}
 If Asian: {{ demos.asian_detail }}
 If Pacific Islander: {{ demos.pacific_detail }}

Ethnicity: {{ demos.ethnicity }} If Hispanic/Latino: {{ demos.ethnicity_detail }}
Place of Birth: {{ demos.place_of_birth }} Preferred Language: {{ demos.language_spoken }} Religion: {{ demos.religion }}
US Citizen: {{ demos.citizen }} US Veteran: {{ demos.veteran }}

Marital Status: {{ demos.marital_status }} Parental Status: {{ demos.parental_status }} Household Composition: {{ demos.household }}

Entitlements
SSN: {{ client.ssn }} Medicaid: {{ client.medicaid }}

Social Security Recipient: {{ ents.social_security }} SSI Amount: {{ ents.ssi }} SSD Amount: {{ ents.ssd }}
Active Medicaid: {{ ents.medicaid }} Medicaid Managed Care: {{ ents.managed_care }}
Medicare Recipient: {{ ents.medicare }} Medicare ID: {{ ents.medicare_id }}

Public Assistance: {{ ents.public_assistance }} Public Assistance Amount: {{ ents.public_amount }}
Section 8: {{ ents.section_8 }}

Private Insurance: {{ ents.insurance }} Insurance Carrier: {{ ents.insurance_carrier }} Insurance ID Number: {{ ents.insurance_id }}

Alimony: {{ ents.alimony }} Child Support: {{ ents.child_support }}

SNAP Recipient: {{ ents.snap }} SNAP ID: {{ ents.snap_id }} SNAP Amount: {{ ents.snap_amt }}
WIC: {{ ents.wic }} TANF: {{ ents.tanf }}
Other Non-Cash Benefits: {{ ents.other_non_cash }}

Wages: {{ ents.wages }} Pension: {{ ents.pension }} Retirement Income: {{ ents.retirement_income }}
Other Income: {{ ents.other_income }}

Unemployment: {{ ents.unemployment }} Workers Compensation: {{ ents.workers_comp }}

VA Disability: {{ ents.va_disability }} VA Medical: {{ ents.va_medical }}
{% for place in places %} {% endfor %} {% for diag in diags %} {% endfor %} {% for funct in functs %} {% endfor %} {% for plan in plans %} {% endfor %} {% for note in notes %} {% endfor %} {% for stay in stays %} {% endfor %}

 
Placement History
Unit Name Admission Discharge Entered By
{{ place.unit_lname }} {{ place.start_date }} {{ place.end_date if place.end_date else 'Current Placement' }} {{ place.staff_name }}

 
Diagnostic History
Effective Date Expiration Date DSM 5 / ICD 10 Diagnoses
{{ diag.start_date }} {{ diag.end_date if diag.end_date else 'Current' }} DSM 5: {{ diag.dsm5 }}
ICD 10: {{ diag.icd10 }}

 
Functional Assessments
Effective Date Expiration Date Skill Area
{{ funct.start_date }} {{ funct.end_date if funct.end_date else 'N/A' }}
  • {{ funct.skill_area|truncate(60, True, '...') }}
    		•

     
    Support Plans
    Effective Date Expiration Date Support Plan Goal
    {{ plan.start_date }} {{ plan.end_date if plan.end_date else 'N/A' }}
      {% for goal in plan.goals %}
    • {{ goal|truncate(60, True, '...') }}
      • {% endfor %}

     
    Progress Notes
    Note Date Note Type Service Reporting Unit
    {{ note.notedate }} {{ 'Case Note' if note.acronym == 'CN' else 'Core Service' }} {{ note.goal|truncate(60, True, '...') }} {{ note.unit_lname }}

     
    Inpatient Stays
    Hospital Hospital Type Admission / Discharge Reporting Unit
    {{ stay.hospital }} {{ stay.hospital_type }} {{ stay.start_date }} - {{ stay.end_date if stay.end_date else 'Active Admission' }} {{ stay.unit_lname }}
    {% include '_footer.html' %}