Treatment Plan
Client: DOB: Intake Date:
Primary Clinician: Other Clinician:
DIAGNOSES* (ICD-10 code before each title; evaluation conducted prior to development of treatment plan)*Based on evaluation by OR consultation with licensed clinician: on
CLIENT & SUPPORT SYSTEM STRENGTHS, ABILITIES, NEEDS & PREFERENCES
Other professional service needs:
Client strengths:
Caregiver strengths:
Client/caregiver limitations:
Client/caregiver preferences:
DJJ/Corrections/DCF legal requirements:
Concurrent disorders: substance abuse developmental disability medically fragile
Legal
SERVICES TO BE PROVIDED (service type/billing code title, frequency & duration)
Individual & Family Therapy ¼ hr units per for
TBOS-Therapy** (Medicaid/CMS only) ¼ hr units per for
¼ hr units per for
TBOS: Intended to prevent more intensive/restrictive behavioral health placement. Justification on problem sheets.
DISCHARGE/TRANSITION PLAN (includes aftercare plan for TBOS services)
Client/caregivers will be prepared for independence Client/caregivers will have natural supports
Referral will be made for new aftercare services Service intensity will be decreased
TBOS aftercare providers/services/activities (**required if TBOS indicated as a service above):
ATTACHMENTS
Problem #1 Description Sheet:
Problem #2 Description Sheet:
Problem #3 Description Sheet:
Problem #4 Description Sheet:
This plan is effective as of ______. The following have participated in the development of this Treatment Plan:
______
Client Signature Date Primary Clinician Signature/Credentials Date
______
Parent Guardian DCM Signature Date Other Participant Signature/Relationship Date
Revised 10/15
Treatment Plan
Client: Intake Date:
Revised 09/14
Treatment Plan
PROBLEM #1 TITLE:Problem definition:
Client desired outcome (in quotes):
Guardian desired outcome (in quotes):
Baseline level/severity (level at intake, include TBOS justification):
Measurable discharge criteria:
Measurable OUTCOME objective to be completed by next review date ( ):
O1:
Assessment/pattern analysis (trigger situations, family dynamics, other contributing variables, where/when):
Description of specific treatment strategies (include strategies for integration into community/family):
Interventions with client individually:
Interventions with support system (family/school/others):
Measurable PROCESS objectives to be completed by next review date ( ):
P1:
P2:
P3:
Client: Intake Date:
Problem definition:
Client desired outcome (in quotes):
Guardian desired outcome (in quotes):
Baseline level/severity (level at intake, include TBOS justification):
Measurable discharge criteria:
Measurable OUTCOME objective to be completed by next review date ( ):
O1:
Assessment/pattern analysis (trigger situations, family dynamics, other contributing variables, where/when):
Description of specific treatment strategies (include strategies for integration into community/family):
Interventions with client individually:
Interventions with support system (family/school/others):
Measurable PROCESS objectives to be completed by next review date ( ):
P1:
P2:
P3:
Client: Intake Date:
Problem definition:
Client desired outcome (in quotes):
Guardian desired outcome (in quotes):
Baseline level/severity (level at intake, include TBOS justification):
Measurable discharge criteria:
Measurable OUTCOME objective to be completed by next review date ( ):
O1:
Assessment/pattern analysis (trigger situations, family dynamics, other contributing variables, where/when):
Description of specific treatment strategies (include strategies for integration into community/family):
Interventions with client individually:
Interventions with support system (family/school/others):
Measurable PROCESS objectives to be completed by next review date ( ):
P1:
P2:
P3:
Client: Intake Date:
Problem definition:
Client desired outcome (in quotes):
Guardian desired outcome (in quotes):
Baseline level/severity (level at intake, include TBOS justification):
Measurable discharge criteria:
Measurable OUTCOME objective to be completed by next review date ( ):
O1:
Assessment/pattern analysis (trigger situations, family dynamics, other contributing variables, where/when):
Description of specific treatment strategies (include strategies for integration into community/family):
Interventions with client individually:
Interventions with support system (family/school/others):
Measurable PROCESS objectives to be completed by next review date ( ):
P1:
P2:
P3:
Revised 09/14