Primary Clinician: Other Clinician

Treatment Plan

Client:DOB: Intake Date:

Primary Clinician: Other Clinician:

DIAGNOSES*based on DSM-IV DSM-5 (evaluation conducted prior to development of treatment plan)
Code:
Code:
Code:
Code:
Code:
Code:
Code:
Code:
*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 Therapy¼ 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/restrictivebehavioral health placement. Justification on problem sheets.
DISCHARGE/TRANSITION PLAN (includes aftercare plan for TBOS services)
Client/caregivers will be prepared for independenceClient/caregivers will have natural supports
Referral will be made for new aftercare servicesService intensity will be decreased
TBOS aftercare providers/services/activities (e.g., professional services, support grps, religious/athletic/hobbies):
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 SignatureDatePrimary Clinician Signature/CredentialsDate

______

Parent Guardian DCM SignatureDateOther Participant Signature/Relationship Date

Revised 01/15

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 #2 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 #3 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 #4 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:

Revised 09/14