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and WELL website to let loved ones know you are <br />OK? <br />How? Serve food, supervise <br />Would you be able or willing to help others in the <br />YES / NO <br />children, organize service teams, <br />shelter? <br />other? <br />TRANSPORTATION <br />Circle <br />Actions to be taken <br />Name of Individual <br />Do you need assistance with transportation? <br />YES / NO <br />If yes, list destination and date /time <br />Do you have any other transportation needs? <br />ADDITIONAL QUESTIONS <br />TO INTERVIEWER <br />Would this person benefit from a more detailed health <br />If yes, refer to Behavioral Health <br />YES / NO <br />or behavioral health assessment? <br />Services <br />REFER to: HS <br />YES / NO <br />If life threatening, call 911. <br />Does the client appear to be overwhelmed, <br />DMH <br />If yes, or unsure, refer <br />disoriented, agitated or a threat to self or others? <br />YES / NO <br />Interviewer <br />immediately to Health Services <br />Initial <br />Can this shelter provide the assistance and support <br />If no, work with Behavior Health <br />/ <br />YES NO <br />needed? <br />Services and Shelter Manager <br />If no or uncertain, consult with <br />Has the person been able to express his /her needs <br />YES / NO <br />Behavioral Health Services and <br />and make choices? <br />Shelter Manager. <br />HS/ DMH signature: <br />Date: <br />Cabarrus County EOP — Annex L — Shelter and Mass Care <br />Attachment umber 12 <br />F -6 Page 290 <br />