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Get and Sign CORE 9 Client Follow Up Record Form Texas Department of State Dshs State Tx
CLIENT FOLLOW-UP RECORD
Address:
Home Phone:
Work Phone:
Emergency contact and phone #:
Description of problems:
Contact Efforts:
Date / Time
Type of Contact (Phone, Letter, Home Visit, etc.)
1st Attempt:
2nd Attempt:
3rd Attempt:
DATE
Comments:
Follow-up Completed on:
Signature/Title
(Date)
Signature:
Client Name
SS#
ID#
Date of Birth
Texas Department of State Health Services
Public Health Nursing
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CORE-9 (10/2004)
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