Breakthrough Request Form
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Breakthrough Request Form - Filled by Family/Stakeholder of the Client
Name
Age
Name of person who you are seeking Intervention for:
Your Relationship with the person:
1. What are the Current challenges/problems of the person?:
2. What are some of the behaviors, actions etc. that you would like to change in the person?:
3. What are their Strengths and Weaknesses/Limitations?:
4. How long have they been suffering with the problem?:
5. Any medical history/ mental health related history? Please describe in detail about the conditions and treatment/medication taken in the past:
6. What would you like as the Ideal Outcome from this intervention for the person?
7. According to you, what is the potential of the person? Once these problems are solved what is your dream, wish for the person? What kind of life will they have after these problems are solved?
8. How will you know when the expected results from the intervention are achieved? Describe in detail - what will be different about the person - in how they look, sound, feel, think, actions etc. What will be different in them?
9. Why is it important to you that the person Overcomes their problems? How will it help you and how will it help them Achieve their life dreams and goals?
10. What do you already know about the unique nature of work that Antano & Harini do?
11. Any other comments
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