Lighthouse for Youth
Treatment Plan:
Name: Jane SmithDOB: 02/26/94Client ID:000001
Admit Date: 12/15/11Primary Client: Dr. Joe Jones
First Review Date: 3/15/12
Next Review Date: 6/15/12
Behavioral Description of Problem / Date / Status: / Status Codes:- Psychological –
Anxiety
PTSD / 3/15/12 / Active / A = Active
I = Inactive
- Education –
Low motivation / 3/15/12 / Active / D = Deferred
R = Resolved
- Family –
Contacting biological parents / 3/15/12 / Active
- Social –
- Personal Hygiene –
- Medical –
- Life skills/Recreation –
Social interaction / 3/15/12 / Deferred
Diagnosis:
Code:Axis I: / Mood Disorder NOS
Post-Traumatic Stress Disorder
Reactive Attachment Disorder of Infancy
Oppositional Defiant Disorder / 296.9
309.81
313.89
313.81
Axis II: / No Diagnosis
Axis III: / No Diagnosis
Axis IV: / No Diagnosis
Axis V: / GAF: 40
Individual Treatment Plan
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 1: Psychological
Objective: Effectively work through mood disorder. Client will learn to control and express emotions appropriately.
Services: Milieu Therapy with case manager daily
Outcome: Client will feel confident expressing emotions and informing staff when problems arise.
Review: 6/15/2012
Objective: Client will identify what triggers mood changes.
Services: Express to staff when negative emotions are arising. Use self-control to
manage emotions and effectively communicate feelings.
Outcome: Client will know what causes mood disorders and know steps to control one’s emotions appropriately.
Review: 6/15/2012
Objective: Client will identify what triggers anxiety.
Service: Therapy 1x per week with Jane Doe about what causes and helps anxiety.
Service: Milieu Therapy as needed with case manager
Outcome: Client will reduce anxiety level when discussing past experiences and visiting adoptive parents.
Review: 6/15/2012
Objective: Client will identify on set of PTSD.
Service: Therapy 1x per week with Jane Doe
Service: Daily communication with adoptive family to build support system.
Service: Participate in volunteer/extracurricular activity to continue building support.
Outcome: Client will be able to discuss past experiences with biological parents that lead to PTSD.
Review: 6/15/2012
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 2: Education
Objective: Client will attend school daily.
Service: Set alarm and wake up on time to take medication and get ready for school.
Service: Make incentive chart related to school attendance. (Attached)
Outcome: Client will attend school daily and be able to attend prom.
Review date: 6/15/2012
Objective: Client will follow routine Monday – Friday.
Service: Client and case manager will create a routine that works for both parties.
Outcome: Client will effectively follow routine and will use routine when transitioning to college in September.
Review: 6/15/2012
Objective: Client will talk with teachers and bring up failing grades due to lack of attendance.
Service: Weekly progress reports checked by case manager.
Service: Client will complete two hours of study time Sunday-Thursday.
Service: IEP Meeting schedule 6/1/2012
Outcome: Client will have all passing grades by end of 4th quarter.
Review: 6/15/2012
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 3: Family
Objective: Client will build a positive, healthy relationship with adoptive mom.
Service: Milieu Therapy with staff about feelings related to adoptive mom.
Service: Client will call adoptive mom weekly and become more comfortable discussing
issues and/or daily activities.
Service: Client will be honest with mom about emotions and feelings related to
relationship.
Outcome: Adoptive mom will become a part of client’s support system. Adoptive mom could be a potential caregiver once client enters college.
Review: 6/15/2012
Objective: Client will discuss and overcome past family issues that affect daily life.
Service: Milieu Therapy with staff about feelings related to family and past situations.
Service: Meet with therapist 1x to discuss any related issues.
Outcome: Client will be able to discuss family without frustration and anger. Client will develop positive feelings toward family members.
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 4: Social
Objective: Client will begin to develop a social support system outside of Lighthouse.
Service: Join extracurricular activities at school, ex. Basketball or track.
Service: Participate in activities provided by Lighthouse with other clients including
Women’s Club and Peer Advocates.
Service:Client will use community time effectively.
Outcome: Client have one positive social relationship and feel comfortable going on pass and spending time with new friends.
Review: 06/15/2012
Objective: Client will identify what causes social anxiety.
Service: Milieu therapy with staff when needed.
Service: Meet with therapist 1x per week to discuss any related issues.
Outcome: Social anxiety will be reduced as client begins to develop healthy friendships.
Review: 06/15/2012
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 5: Personal Hygiene
Objective: Client will create and follow a daily personal hygiene routine.
Service: Staff will assist client in creating a personal hygiene routine.
Service: Staff will follow up with client daily.
Service: Milieu therapy if necessary to discuss difficulties following personal hygiene
routine.
Outcome: Client will follow daily personal hygiene routine without prompts from staff.
Review 6/15/2012
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 6: Medical
Objective: No objectives at this time.
Review: 6/15/2012
Name: Jane SmithDOB: 02/26/94Client ID: 000001
Problem # and Title 7: Life Skills and Recreation
Objective: Client will learn basic independent skill. (Ex. banking)
Service: Client will participate in Life Skills offered by the state, June 20-25th.
Service: Client will open bank account after Life Skills course.
Service: Client will receive
Outcome: Client will feel confident using basic independent skills. Client will begin saving money and utilizing skills when needed.
Inactive
Review: 09/15/2012
Objective: Client will participate in recreational activities offered by state and in the neighborhood.
Service: Participate in one volunteer opportunity.
Service: Attend one event advertised by the Department of Children, Youth and
Families.
Service: Client will actively look for job opportunities in the surrounding area.
Outcome: Client will learn time management and utilize skills learned at Life Skills.
Inactive
Review: 09/15/2012