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["依頼元","依頼者所属",null,null,null,null,null,"依頼者氏名"]
[null,"依頼者連絡先",null,null,null,null,null,"本人との関係"]
["本人状況","性別",null,"男性",null,"女性",null,"年齢",null,null,null,null,false,false]
[null,"現在の居所","（市区町村名）",null,null,null,null,"住民票住所","（市区町村名）"]
[null,"転居予定先","（市区町村名）",null,null,null,null,"転居予定時期"]
[null,"居所の状況",null,"自宅（所有）",null,"自宅（借間等）",null,"グループホーム",null,"有料老人ホーム",null,"サービス付き高齢者住宅",false,false,false,false,false]
[null,null,null,"病院",null,"特別養護老人ホーム",null,"老人保健施設",null,"その他　→",null,null,false,false,false,false]
[null,"最寄り駅","路線\n 駅",null,null,null,null,"徒歩",null,"バス",null,"分",false,false]
[null,"疾病・障害等",null,"認知症",null,"知的障害",null,"精神障害",null,"その他　→",null,null,false,false,false,false]
[null,"要介護認定",null,"非該当",null,"申請中",null,"区分変更中",null,"要支援１",null,"要支援２",false,false,false,false,false]
[null,null,null,"要介護１",null,"要介護２",null,"要介護３",null,"要介護４",null,"要介護5",false,false,false,false,false]
[null,"愛の手帳",null,"4度",null,"3度",null,"2度",null,"1度",null,"身体（詳細は概況へ）",false,false,false,false,false]
[null,"精神保健福祉手帳\n",null,"3級",null,"2級",null,"1級",null,null,null,"難病（詳細は概況へ）",false,false,false,false]
[null,"障害支援区分",null,"区分１～２",null,"区分３",null,"区分4",null,"区分５",null,"区分６",false,false,false,false,false]
[null,"コミュニ\nケーション",null,"支障なし",null,"簡単な会話可",null,"あいさつ可",null,"YES/NO可",null,"表情等で把握",false,false,false,false,false]
[null,null,null,"難聴",null,"筆談",null,"手話",null,"コミュニケーションは取れない",null,null,false,false,false,false]
["経済状況","収入","円/月",null,null,"老齢年金等",null,"障害年金",null,"生活保護",null,"賃金等",false,false,false,false]
[null,null,null,"その他　→",null,null,null,null,null,null,null,"不明",false,false]
[null,"支出","円/月",null,null,"入院・施設費",null,"家賃",null,"生活費",null,"医療・介護費",false,false,false,false]
[null,null,null,"その他　→",null,null,null,null,null,null,null,"不明",false,false]
[null,"預貯金等",null,"預貯金","金額",null,null,"株式等",null,"生命保険",null,"不明",false,false,false,false]
[null,"その他の資産",null,"居住用不動産",null,"非居住用不動産",null,"その他　→",null,null,null,"不明",false,false,false,false]
[null,"負債",null,"なし",null,"家賃",null,"入院費・施設費",null,"生活保護返還金",null,"税金・保険料等",false,false,false,false,false]
[null,null,null,"親族立替金",null,"不明",null,"その他　→",null,null,"金額",null,false,false,false]
["支援事業","当該自治体の\n報酬助成要件",null,"首長申立",null,"生活保護",null,"非課税世帯",null,"預貯金　→","以下",null,false,false,false,false]
[null,"当該案件は\n報酬助成に",null,"該当する",null,"該当しない",null,"不明",null,"その他　→",null,null,false,false,false,false]
["申立","本人情報シート",null,null,null,"あり",null,"なし",null,"作成予定",null,"不明・未定",false,false,false,false]
[null,"支援検討会議等の協議",null,null,null,"あり",null,"なし",null,"紹介期限月日→",null,null,false,false,false]
[null,"候補者が決まらない場合",null,null,null,"他団体に依頼",null,"候補者なしで申立",null,"その他　→",null,null,false,false,false]
[null,"類型見立",null,"後見",null,"保佐",null,"補助",null,"診断書取得済",null,"任意後見",false,false,false,false,false]
[null,"申立人",null,"本人",null,"親族",null,"首長",null,"その他　→",null,null,false,false,false,false]
[null,"申立て理由",null,"金銭管理",null,"入院入所契約",null,"借間等解約",null,"財産処分等",null,"債務整理",false,false,false,false,false]
[null,null,null,"相続",null,"虐待対応",null,"その他　→",null,null,null,null,false,false,false]
["本人の意向","本人にとって\n望ましい\n候補者の条件","本人の希望　→"]
[null,null,null,"男性希望",null,"女性希望",null,"その他　→",null,null,null,null,false,false,false]
[null,"申立について",null,"説明している",null,"説明していない",null,"理解できている",null,"理解できていない",null,"理解は不明",false,false,false,false,false]
[null,"今後の生活についての意向"]
[]
[]
[null,"手伝って\nほしいこと"]
[]
[]
[null,"大切にして\nいる価値観"]
[]
[]
["親族","親族",null,"配偶者",null,"子",null,"親",null,"きょうだい",null,"甥姪",false,false,false,false,false]
[null,null,null,"その他　→",null,null,null,null,null,null,null,null,false]
[null,"親族との関係"]
[]
[]
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[null,null,null,"介護支援専門員",null,"通所介護",null,"訪問介護",null,"訪問看護",null,"医師",false,false,false,false,false]
[null,null,null,"地域包括",null,"施設職員",null,"医療相談員",null,"相談支援専門員",null,"障害者支援施設",false,false,false,false,false]
[null,null,null,"その他　→",null,null,null,null,null,null,null,null,false]
["経緯","生活歴"]
[]
[]
[]
[null,"概況"]
[]
[]
[]
[]
[]
[]
[null,"個人情報は記載しないでください"]