Are you looking for a way to improve your treatment plan form? If so, you may benefit from using a template treatment plan form.Template treatment plan forms are designed to help you create a well- organized and effective treatment plan. They can also help ensure that all the necessary information is included in your treatment plan. By using a template, you can be sure that your form meets all the requirements set by insurance companies and other organizations.
You will discover info about the type of form you would like to submit in the table. It will tell you how long it will take to finish template treatment plan, exactly what fields you need to fill in, and so forth.
Question | Answer |
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Form Name | Template Treatment Plan |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | therapy treatment plan template, mental health treatment plan template printable, printable treatment plan, treatment plan template pdf |
This is a fictitious case. All names used in the document are fictitious
Sample Treatment Plan
Recipient Information |
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Provider Information |
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Medicaid Number:12345678 |
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Medicaid Number:987654321 |
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Name: Jill Spratt |
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Name: Tom Thumb, Ph.D. |
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DOB: |
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Treatment Plan Date |
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Other Agencies Involved: |
Plan to Coordinate Services: |
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Jack Horner, M.D., Child |
Phone contact during the first month of treatment, then as needed, but at least |
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Psychiatrist |
1 time every 3 months. |
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Spring Hill Middle School |
Request teacher to complete Achenbach teacher Report Form (TRF) 1 time |
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during the first month of treatment. Continued contact by phone as needed. |
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Medication(s): |
Dose: |
Frequency: |
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Indication: |
Prozac |
20 mg |
1 x day |
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depression |
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1. Problem/Symptom: Depression as manifested by sadness, irritability, poor
Long Term Goal: Symptoms of depression will be significantly reduced and will no longer interfere with Jill’s functioning. This will be measured by a t score of 60 or below on the YSR Withdrawn/Depressed scale at the time
of discharge. |
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Anticipated completion date: |
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Short Term Goals/Objectives: |
Date Established |
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Date Acheived |
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Completion Date |
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1. Jill and her father will develop a safety plan/no |
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contract |
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2. Jill will become involved in at least one additional |
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extracurricular activity or sport |
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3. Jill will report no suicidal ideation for 3 consecutive |
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weeks |
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4. Jill will learn coping skills, including problem solving and |
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emotional regulation. This will be measured by her |
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demonstrating these skills during therapy sessions and |
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bringing in homework assignments for two consecutive |
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weeks that show she practiced them between sessions. |
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5. Jill will learn to identify maladaptive, negative thoughts |
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and how to replace them with more positive, adaptive |
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thoughts. This will be measured by her demonstrating |
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these skills during therapy sessions and bringing in |
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homework assignments for two consecutive weeks that |
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show she practiced them between sessions. |
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Intervention/Action |
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Responsible Person(s) |
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1. |
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Individual therapy to help Jill learn and implement |
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Tom Thumb, Ph.D. |
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coping skills and to help her identify, process and |
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resolve feelings and concerns. |
2.Jill Spratt |
3. |
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Intervention/actions: |
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Responsible Person(s): |
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Family Therapy to develop safety plan/no self harm |
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Tom Thumb, Ph.D. |
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contract, provide |
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2. |
3. |
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to increase parents’ insight into Jill, and to increase |
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Jill Spratt |
Jack and Joan Spratt, father and |
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parents’ ability to support and encourage Jill to utilize |
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new coping skills. |
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Intervention/actions: |
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Responsible Person(s): |
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Medication Management |
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Jack Horner, M.D. |
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2. |
3. |
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Intervention/actions: |
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Responsible Person(s): |
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2. |
3. |
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Review Date: |
Progress: |
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Review Date: |
Progress: |
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2. Problem/Symptom: Family Conflict as manifested by poor communication between Jill and her father, rude comments towards her
Long Term Goal: Reduce family conflict and increase positive family interactions. This will be measured by reducing evasive/withdrawn interactions with her father to 1 time a week for 3 consecutive weeks; reducing arguing/rudeness towards her
Anticipated completion date:
Short Term Goals/Objectives: |
Date Established |
Projected |
Date Achieved |
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Completion Date |
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1. Gather baseline data on evasive/withdrawn interactions |
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with father and arguing/rudeness with |
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2. Family will establish routine times in the week for |
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communication and/or family activities (i.e., family meetings, |
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family fun nights). This will be measured by the family |
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establishing a schedule for communication/activities and |
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reporting the number of times each week that they followed |
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the schedule. |
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3. Jill and her father will learn communication and conflict |
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resolution skills. This will be measured by Jill and her father |
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demonstrating the skills, without coaching, to successfully |
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discuss and resolve issues in 2 consecutive family therapy |
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sessions. |
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4. Jill and her |
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conflict resolution skills. This will be measured by Jill |
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and her |
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coaching, to successfully discuss and resolve issues in |
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2 consecutive family therapy sessions. |
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5. Reduce evasive/withdrawn interactions with father to 3 |
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times a week |
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6. Reduce arguing/rudeness to |
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week |
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7. Reduce evasive/withdrawn interactions with father to 1 |
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time a week. |
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8. Reduce arguing/rudeness to |
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week. |
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Intervention/actions: |
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Responsible Person(s): |
1. |
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Family Therapy to explore and help family understand |
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Tom Thumb, Ph.D. |
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family dynamics, negative patterns and problems in |
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2. |
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3. |
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family structure; and to help family learn and use |
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Jill Spratt |
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Jack and Joan Spratt, father and step- |
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communication and conflict resolution skills. |
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mother |
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Intervention/actions: |
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Responsible Person(s): |
1. |
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Individual Therapy to explore, process and resolve |
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Tom Thumb, Ph.D. |
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Jill’s feelings about family members, rules and |
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2.Jill Spratt |
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3. |
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structure; and to reinforce using good communication, |
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conflict resolution and coping skills at home. |
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Intervention/actions: |
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Responsible Person(s): |
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2. |
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3. |
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Intervention/actions: |
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Responsible Person(s): |
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2. |
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3. |
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Review Date: |
Progress: |
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Review Date: |
Progress: |
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Involvement of Family: Father and
Services Needed beyond scope of organization or program:
Medication Management by Dr. Jack Horner
Estimated Completion date for level of care:
Patient /Responsible Party Signature:
Provider Signature: TOM THUMB, PH.D.
Must be a true signature,
Rubber stamp signatures are not allowed Electronic signatures are acceptable
Date:
Provider Name/Title: (Print)
Tom Thumb, Ph.D., Licensed Psychologist