VAN BUREN COUNTY SBMH
851 Yellowjacket Lane
Clinton, AR 72031 1.
MASTER TREATMENT PLAN
/Client
/ /Medicaid #V Status ARKIDS B
/Date of Plan / Next Review By / Projected D/C date, # of Sessions
/
Place of MTP/TPR Clinton JR HighClinton SR HighClinton ElemClinton Inter.Southside Elem.Southside PreKSouthside JR HighSouthside SR HighShirley Elem.Shirley Jr. HighShirley Sr. HighALESALCClinton PreK
/Time In 8:308:459:009:159:309:4510:0010:1510:3010:4511:0011:1511:3011:4512:001:001:151:301:452:002:152:302:453:00 Time Out 8:308:459:009:159:309:4510:0010:1510:3010:4511:0011:1511:3011:4512:001:001:151:301:452:002:152:302:453:00
DSM-IV Diagnosis/ CODE / DESCRIPTION
/ AXIS I / Bipolar Affective Disorder (Bipolar I D/O) [296.Unspecified Psychosis (Psychotic D/O NOS) [298.9]Schizophrenic Disorder (Schizophrenia) [295.Schizophrenic D/O; Schizoaffective Type [295.70]Unspecified Affective Psychosis (Mood D/O)[296.90]Neurotic Depression (Dysthymic D/O) [300.4]Depressive Disorder,not elsewhere classified [311]Manic-Depressive Psychosis (Bipolar II) [296.89]Bipolar Affective Disorder, unspecified [296.7]Anxiety State, unspecified (Anxiety NOS) [300.00] Prolonged Posttraumatic Stress D/O (PTSD) [309.81]Generalized Anxiety Disorder (GAD) [300.02]Obsessive-Compulsive Disorder (OCD) [300.3]Impulsive Control Disorder, unspecified [312.30]Intermittent Explosive Disorder [312.34]Adjustment Reaction (Adjustment D/O) [309.Unspecified Drug Dependence [304.90]Alcohol Abuse [305.00]Cannabis Abuse [305.20]Tobacco Use Disorder (Nicotine Dependence) [305.1]Eating Disorder, unspecified (NOS) [307.50]Major Depressive D/O recurrent, mild (296.31)Major Depressive D/O, single,Unspecified (296.2)Major Depressive Disorder,recurrent,unspec.(296.3) Unsp. Disturbance of Conduct (DisruptiveBx)[312.9]Conduct Disorder, childhood onset type [312.81]Conduct Disorder, adolescent onset type [312.82]Oppositional Disorder (ODD) [313.81]Attention Deficit D/O; w/o Hyperactivity [314.00]Attention Deficit D/O; with Hyperactivity [314.01]Unspecified Delay in Development (Learning)[315.9]Reading Disorder, unspecified [315.00]Specific Arithmetical Disorder (Math D/O) [315.1]Other Spec. Learning Difficulties (Writing)[315.2]Other Special Syndromes (Communication D/O)[307.9]Developmental Language D/O (Expressive) [315.31]Receptive Language Disorder (Mixed) [315.32]Tic Disorder, unspecified (Tic D/O NOS) [307.20]Gilles de la Tourette's D/O (Tourette's) [307.23]Enuresis [307.6]Encopresis [307.7]Other Mixed Disturbances of Childhood(RAD)[313.89]Child Neglect (nutritional) (victim) [995.52]Chid Sexual Abuse (victim) [995.53]Child Physical Abuse (victim) [995.54]Counseling for Child Abuse (perpetrator) [V61.21]Autism [299.00]Pervasive Developmental D/O NOS (299.8)
/ Unspecified Psychosis (Psychotic D/O NOS) [298.9]Schizophrenic Disorder (Schizophrenia) [295.Schizophrenic D/O; Schizoaffective Type [295.70]Unspecified Affective Psychosis (Mood D/O)[296.90]Major Depressive Disorder [296.Neurotic Depression (Dysthymic D/O) [300.4]Depressive Disorder,not elsewhere classified [311]Bipolar Affective Disorder (Bipolar I D/O) [296.Manic-Depressive Psychosis (Bipolar II) [296.89]Cyclothymic Disorder [301.13]Bipolar Affective Disorder, unspecified [296.7]Anxiety State, unspecified (Anxiety NOS) [300.00] Panic Disorder [300.01]Prolonged Posttraumatic Stress D/O (PTSD) [309.81]Generalized Anxiety Disorder (GAD) [300.02]Obsessive-Compulsive Disorder (OCD) [300.3]Impulsive Control Disorder, unspecified [312.30]Intermittent Explosive Disorder [312.34]Adjustment Reaction (Adjustment D/O) [309.Unspecified Drug Dependence [304.90]Alcohol Abuse [305.00]Cannabis Abuse [305.20]Tobacco Use Disorder (Nicotine Dependence) [305.1]Eating Disorder, unspecified (NOS) [307.50] Unsp. Disturbance of Conduct (DisruptiveBx)[312.9]Conduct Disorder, childhood onset type [312.81]Conduct Disorder, adolescent onset type [312.82]Oppositional Disorder (ODD) [313.81]Attention Deficit D/O; w/o Hyperactivity [314.00]Attention Deficit D/O; with Hyperactivity [314.01]Unspecified Delay in Development (Learning)[315.9]Reading Disorder, unspecified [315.00]Specific Arithmetical Disorder (Math D/O) [315.1]Other Spec. Learning Difficulties (Writing)[315.2]Other Special Syndromes (Communication D/O)[307.9]Developmental Language D/O (Expressive) [315.31]Receptive Language Disorder (Mixed) [315.32]Other Sp. Early Childhood Psychoses (PDD) [299.80]Infantile Autism (Autistic D/O) [299.00]Tic Disorder, unspecified (Tic D/O NOS) [307.20]Gilles de la Tourette's D/O (Tourette's) [307.23]Enuresis [307.6]Encopresis [307.7]Other Mixed Disturbances of Childhood(RAD)[313.89]Child Neglect (nutritional) (victim) [995.52]Chid Sexual Abuse (victim) [995.53]Child Physical Abuse (victim) [995.54]Counseling for Child Abuse (perpetrator) [V61.21]
/ Unspecified Psychosis (Psychotic D/O NOS) [298.9]Schizophrenic Disorder (Schizophrenia) [295.Schizophrenic D/O; Schizoaffective Type [295.70]Unspecified Affective Psychosis (Mood D/O)[296.90]Major Depressive Disorder [296.Neurotic Depression (Dysthymic D/O) [300.4]Depressive Disorder,not elsewhere classified [311]Bipolar Affective Disorder (Bipolar I D/O) [296.Manic-Depressive Psychosis (Bipolar II) [296.89]Cyclothymic Disorder [301.13]Bipolar Affective Disorder, unspecified [296.7]Anxiety State, unspecified (Anxiety NOS) [300.00] Panic Disorder [300.01]Prolonged Posttraumatic Stress D/O (PTSD) [309.81]Generalized Anxiety Disorder (GAD) [300.02]Obsessive-Compulsive Disorder (OCD) [300.3]Impulsive Control Disorder, unspecified [312.30]Intermittent Explosive Disorder [312.34]Adjustment Reaction (Adjustment D/O) [309.Unspecified Drug Dependence [304.90]Alcohol Abuse [305.00]Cannabis Abuse [305.20]Tobacco Use Disorder (Nicotine Dependence) [305.1]Eating Disorder, unspecified (NOS) [307.50] Unsp. Disturbance of Conduct (DisruptiveBx)[312.9]Conduct Disorder, childhood onset type [312.81]Conduct Disorder, adolescent onset type [312.82]Oppositional Disorder (ODD) [313.81]Attention Deficit D/O; w/o Hyperactivity [314.00]Attention Deficit D/O; with Hyperactivity [314.01]Unspecified Delay in Development (Learning)[315.9]Reading Disorder, unspecified [315.00]Specific Arithmetical Disorder (Math D/O) [315.1]Other Spec. Learning Difficulties (Writing)[315.2]Other Special Syndromes (Communication D/O)[307.9]Developmental Language D/O (Expressive) [315.31]Receptive Language Disorder (Mixed) [315.32]Other Sp. Early Childhood Psychoses (PDD) [299.80]Infantile Autism (Autistic D/O) [299.00]Tic Disorder, unspecified (Tic D/O NOS) [307.20]Gilles de la Tourette's D/O (Tourette's) [307.23]Enuresis [307.6]Encopresis [307.7]Other Mixed Disturbances of Childhood(RAD)[313.89]Child Neglect (nutritional) (victim) [995.52]Chid Sexual Abuse (victim) [995.53]Child Physical Abuse (victim) [995.54]Counseling for Child Abuse (perpetrator) [V61.21]
/ Unspecified Psychosis (Psychotic D/O NOS) [298.9]Schizophrenic Disorder (Schizophrenia) [295.Schizophrenic D/O; Schizoaffective Type [295.70]Unspecified Affective Psychosis (Mood D/O)[296.90]Major Depressive Disorder [296.Neurotic Depression (Dysthymic D/O) [300.4]Depressive Disorder,not elsewhere classified [311]Bipolar Affective Disorder (Bipolar I D/O) [296.Manic-Depressive Psychosis (Bipolar II) [296.89]Cyclothymic Disorder [301.13]Bipolar Affective Disorder, unspecified [296.7]Anxiety State, unspecified (Anxiety NOS) [300.00] Panic Disorder [300.01]Prolonged Posttraumatic Stress D/O (PTSD) [309.81]Generalized Anxiety Disorder (GAD) [300.02]Obsessive-Compulsive Disorder (OCD) [300.3]Impulsive Control Disorder, unspecified [312.30]Intermittent Explosive Disorder [312.34]Adjustment Reaction (Adjustment D/O) [309.Unspecified Drug Dependence [304.90]Alcohol Abuse [305.00]Cannabis Abuse [305.20]Tobacco Use Disorder (Nicotine Dependence) [305.1]Eating Disorder, unspecified (NOS) [307.50] Unsp. Disturbance of Conduct (DisruptiveBx)[312.9]Conduct Disorder, childhood onset type [312.81]Conduct Disorder, adolescent onset type [312.82]Oppositional Disorder (ODD) [313.81]Attention Deficit D/O; w/o Hyperactivity [314.00]Attention Deficit D/O; with Hyperactivity [314.01]Unspecified Delay in Development (Learning)[315.9]Reading Disorder, unspecified [315.00]Specific Arithmetical Disorder (Math D/O) [315.1]Other Spec. Learning Difficulties (Writing)[315.2]Other Special Syndromes (Communication D/O)[307.9]Developmental Language D/O (Expressive) [315.31]Receptive Language Disorder (Mixed) [315.32]Other Sp. Early Childhood Psychoses (PDD) [299.80]Infantile Autism (Autistic D/O) [299.00]Tic Disorder, unspecified (Tic D/O NOS) [307.20]Gilles de la Tourette's D/O (Tourette's) [307.23]Enuresis [307.6]Encopresis [307.7]Other Mixed Disturbances of Childhood(RAD)[313.89]Child Neglect (nutritional) (victim) [995.52]Chid Sexual Abuse (victim) [995.53]Child Physical Abuse (victim) [995.54]Counseling for Child Abuse (perpetrator) [V61.21]
/ AXIS II / V71.09 No Diagnosis799.9 Diagnosis DeferredUnspecified Mental Retardation [319]Other Psychological Stress (Borderline IQ)[V62.89]Mild Mental Retardation [317]Moderate Mental Retardation [318.0]Severe Mental Retardation [318.1]Profound Mental Retardation [318.2]R/O Borderline Intellectual FunctioningR/O Mental RetardationUnspecified Personality Disorder (NOS) [301.9]Antisocial Personality Disorder [301.7]Avoidant Personality (Disorder) [301.82]Borderline Personality (Disorder) [301.83]Compulsive Personality Disorder (OCPD) [301.4]Dependent Personality Disorder [301.6]Histrionic Personality Disorder [301.50]Narcissistic Personality (Disorder) [301.81]Paranoid Personality Disorder [301.0]Schizoid Personality Disorder [301.20]Schizotypal Personality (Disorder) [301.22] No DiagnosisUnspecified Mental Retardation [319]Other Psychological Stress (Borderline IQ)[V62.89]Mild Mental Retardation [317]Moderate Mental Retardation [318.0]Severe Mental Retardation [318.1]Profound Mental Retardation [318.2]R/O Borderline Intellectual FunctioningR/O Mental RetardationUnspecified Personality Disorder (NOS) [301.9]Antisocial Personality Disorder [301.7]Avoidant Personality (Disorder) [301.82]Borderline Personality (Disorder) [301.83]Compulsive Personality Disorder (OCPD) [301.4]Dependent Personality Disorder [301.6]Histrionic Personality Disorder [301.50]Narcissistic Personality (Disorder) [301.81]Paranoid Personality Disorder [301.0]Schizoid Personality Disorder [301.20]Schizotypal Personality (Disorder) [301.22]
/ No DiagnosisUnspecified Mental Retardation [319]Other Psychological Stress (Borderline IQ)[V62.89]Mild Mental Retardation [317]Moderate Mental Retardation [318.0]Severe Mental Retardation [318.1]Profound Mental Retardation [318.2]R/O Borderline Intellectual FunctioningR/O Mental RetardationUnspecified Personality Disorder (NOS) [301.9]Antisocial Personality Disorder [301.7]Avoidant Personality (Disorder) [301.82]Borderline Personality (Disorder) [301.83]Compulsive Personality Disorder (OCPD) [301.4]Dependent Personality Disorder [301.6]Histrionic Personality Disorder [301.50]Narcissistic Personality (Disorder) [301.81]Paranoid Personality Disorder [301.0]Schizoid Personality Disorder [301.20]Schizotypal Personality (Disorder) [301.22] No DiagnosisUnspecified Mental Retardation [319]Other Psychological Stress (Borderline IQ)[V62.89]Mild Mental Retardation [317]Moderate Mental Retardation [318.0]Severe Mental Retardation [318.1]Profound Mental Retardation [318.2]R/O Borderline Intellectual FunctioningR/O Mental RetardationUnspecified Personality Disorder (NOS) [301.9]Antisocial Personality Disorder [301.7]Avoidant Personality (Disorder) [301.82]Borderline Personality (Disorder) [301.83]Compulsive Personality Disorder (OCPD) [301.4]Dependent Personality Disorder [301.6]Histrionic Personality Disorder [301.50]Narcissistic Personality (Disorder) [301.81]Paranoid Personality Disorder [301.0]Schizoid Personality Disorder [301.20]Schizotypal Personality (Disorder) [301.22]
/ AXIS III / enuresisencopresisNo DiagnosisAsthmaBlindnessBowel ImpactionCerebral PalsyDeafnessDiabetes MellitusFetal Alcohol SyndromeH/O Closed Head InjuryH/O Drug Exposure En UteroH/O Head TraumaH/O SeizuresHead LiceHearing ImpairmentHeart MurmurHypertensionHypothyroidismMalnutritionMorbid ObesityObesitySeizure DisorderVision Impairment No DiagnosisAsthmaBlindnessBowel ImpactionCerebral PalsyDeafnessDiabetes MellitusFetal Alcohol SyndromeH/O Abnormal EEGH/O Closed Head InjuryH/O Drug Exposure En UteroH/O Head TraumaH/O SeizuresHead LiceHearing ImpairmentHeart MurmurHyperprolactinemiaHypertensionHypothyroidismMalnutritionMorbid ObesityObesitySeizure DisorderVision Impairment
/ No DiagnosisAsthmaBlindnessBowel ImpactionCerebral PalsyDeafnessDiabetes MellitusFetal Alcohol SyndromeH/O Abnormal EEGH/O Closed Head InjuryH/O Drug Exposure En UteroH/O Head TraumaH/O SeizuresHead LiceHearing ImpairmentHeart MurmurHyperprolactinemiaHypertensionHypothyroidismMalnutritionMorbid ObesityObesitySeizure DisorderVision Impairment No DiagnosisAsthmaBlindnessBowel ImpactionCerebral PalsyDeafnessDiabetes MellitusFetal Alcohol SyndromeH/O Abnormal EEGH/O Closed Head InjuryH/O Drug Exposure En UteroH/O Head TraumaH/O SeizuresHead LiceHearing ImpairmentHeart MurmurHyperprolactinemiaHypertensionHypothyroidismMalnutritionMorbid ObesityObesitySeizure DisorderVision Impairment
/ AXIS IV / Problem with / Recent Loss Abuse Legal Separation/Divorce Education
Custody/Placement Financial Change in Living Situation
Other
/ AXIS V / GAF 70-61 Difficulty in one area60-51 Variable functioning in several social areas50-41 Moderate degree of interference41- under Refer for outside services / Highest GAF in past year
Parent/Client Input regarding treatment/progress
Reviewed by Phone Conference Therapy Session
Parent’s/Guardian signature ______Date______
Client’s signature (if 5 or older)______Date______Current Medications/dosage No medications
Changes in medical/nutritional status no change
Signatures of the Treatment Team Members:
Supervisor/Licensed Clinician Title Date / Name Title Date
Therapist Title Date / Name Title Date
Created 3/1/06
Discharge Plan:
/Projected D/C date:
/Level of care needed at transfer/discharge:
Out PatientDay Treatment
Special Education
Residential /
School Counselor
No Services AnticipatedMaintenance
Acute /
Social Skill group
Case managementOther, Specify:
Parenting and/or Community Resources
Services needed at discharge/transfer: Individual Group Family Medication On-site/Off-site
Crisis Intervention/Stabilization Other:
Community resources needed at discharge: Shelter Other:
Living situation:
Educational placement:
Goal #1-Describe current symptoms with particular focus on nature, severity, extent, and duration of symptoms.
#1 / Problems depressive behaviorsBehaviors exhibited / Severity / Frequency / Duration
a. Sad affect / mild / weekly / 3-6 months
b. Mood irritability / mild / daily / 3-6 months
c.Lack of interest in previously enjoyed activities / mild / daily / 3-6 months
d.
e.
Goal # / 1 / Client will meet objectives 1, 2, and 3 for 30 consecutive days without impairment of functioning
Problems Addressed #a-c Goal/Discharge Criteria #1 (behaviorally specific and measurable) Client will express feelings for 4 consecutive weeks without any impairment in school or at home.
Start Date / Target Date of Completion / Actual Date of Completion
Objective #1 - Client will verbally acknowledge the depression and will express feelings of sadness/anger/frustration for 4 consecutive weeks with parent(s)/guardian(s) responding calmly to these verbalizations.
Start Date Target Date
Service and Rationale: Individual, Group, and/or Family therapy, On/Off-site and Collateral Interventions, Medication evaluation and/or management / Frequency / Responsible Staff
Client will complete depression assessment and family will be educated about depressive symptoms and the results of the assesment. / 2-4 times / therapist
Teach client to chart daily emotions in order to establish patterns and process this information in therapy / 2-6 times monthly / therapist
Support the client’s expression of emotional needs to family members and significant others and work with the parents to develop their abilities to encourage, support, and tolerate this expression of the client’s thoughts and feelings / 2-6 times monthly / therapist
Medication evaluation and management to decrease depressive behaviors and thoughts / 1-2 times monthly / Psychiatrist/Physician
Objective #2 - Client will detect automatic negative thinking/behaviors and replace with positive thinking and healthier behavior patterns.
Start Date Target Date
Service and Rationale: Individual, Group, and/or Family therapy, On/Off-site and Collateral Interventions / Frequency / Responsible Staff
Assess the cognitive messages that the client gives to him/herself that reinforce feelings of helplessness and hopelessness. / 2-6 times monthly / therapist
Teach, monitor, and reinforce the use of positive cognitive messages that facilitate the growth of the client’s self-confidence and self-acceptance. / 2-6 times monthly / therapist
Role-play situations involving negative and positive reactions, modeling positive cognitive/behavioral responses. / 2-6 times monthly / therapist
Objective #3 - Client will reduce irritability and anger as evidenced by an increase in levels of pleasant social interactions with family and friends, energy, and participation in usual activities.
Start Date Target Date
Service and Rationale : Individual, Group, and/or Family therapy, On/Off-site and Collateral Interventions / Frequency / Responsible Staff
Encourage the client’s participation in social/recreational activities that enrich life. / 2-6 times monthly / therapist
Facilitate the expression of conflict with family members. / 2-6 times monthly / therapist
Objective #4
Start Date Target Date
Service and Rationale / Frequency / Responsible Staff
Goal #2-Describe current symptoms with particular focus on nature, severity, extent, and
duration of symptoms.
# ; / # / ProblemsBe Be Behaviors exhibited / Severity / Frequency / Duration
a. Little or no eye contact and frequent verbalizations of low self-esteem / moderate / daily / 3-6 months
b. / b.Feelings of hopelessness, worthlessness, or inappropriate guilt / moderate / daily / 3-6 months
c. / c.anxiety and fear
d. / d.
e. / e.
Goal # / 2 / Client will meet objectives 1and 2 for 30 consecutive days without impairment of functioning
Problems Addressed: #a-c Goal/Discharge Criteria #2 (behaviorally specific and measurable)Client will openly discuss feelings of unhapiness for 4 consecutive weeks without any impairment in school or home.
Start Date / Target Date of Completion / Actual Date of Completion
Objective #1 - Specify what in the past or present life or what is missing from life that contributes to the feelings of unhappiness that the client experiences. - Start Date Target Date
Service and Rationale: : Individual, Group, and/or Family therapy, On/Off-site and Collateral Interventions / Frequency / Responsible Staff
Reinforce the client’s open expression of underlying feelings of anger, hurt, and disappointment / 2-6 times monthly / therapist
Probe present aspects of the client’s life that contribute to the sadness. / 2-6 times monthly / therapist
Ask the client what is missing from his/her life that contributes to the unhappiness. / 2-6 times monthly / therapist
Reinforce, support, and monitor eye contact while promoting high self esteem / 2-6 times monthly / therapist
Objective #2 Client will identify areas of conflict or anxiety provoking situations in his/her life and learn to resolve them in order to reduce anxiety
Start Date Target Date
Service and Rationale: : Individual, Group, and/or Family therapy, On/Off-site and Collateral Interventions / Frequency / Responsible Staff
Develop a coping plan including use of relaxation techniques / 2-6 times monthly / therapist
Determine past and present conflicts within the family and with peers / 2-6 times monthly / therapist
teach, monitor and reinforce client utilization of anxiety decreasing methods. / 2-6 times monthly / therapist
Clarify cognitions in anxiety provoking situations (negative unrealistic thoughts or expectations) / 2-6 times monthly / therapist
Objective #3
Start Date Target Date
Service and Rationale : / Frequency / Responsible Staff
Objective #4 Progress at Review
Start Date Target Date
Service and Rationale / Frequency / Responsible Staff
Goal #3-Describe current symptoms with particular focus on nature, severity, extent, and