Turning Point Family CARE, PLLC
Level 1 Incident Report
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Consumer Name
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Medical Record Number
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Date of Birth
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Date of Incident:
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Time:
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What County did this incident occur?
Wake
Durham
Johnston
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Please provide the specific location of the incident?
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Witness to Incident:
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Who is responsible for adding this information to the consumer's crisis plan:
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Description of Incident / what was happening before the incident occurred:
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Any additional Comments, or any other parties involved:
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I attest the information is true and accurate to the best of my ablity. I understand that this incident report will be forwarded to the Clinical Director and Medical Director for review, and that I have submitted this document within 24 hours of being notified of the incident. I also understand that the Medical Director or Clinical Director may contact me for additional information, supervison, or follow-up information.
YES
NO
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Staff Name Submitting this Form:
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Indicates Response Required