Treatment Plan Template Pdf Details

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.

QuestionAnswer
Form NameTemplate Treatment Plan
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namestherapy treatment plan template, mental health treatment plan template printable, printable treatment plan, treatment plan template pdf

Form Preview Example

This is a fictitious case. All names used in the document are fictitious

Sample Treatment Plan

Recipient Information

 

Provider Information

Medicaid Number:12345678

 

Medicaid Number:987654321

Name: Jill Spratt

 

Name: Tom Thumb, Ph.D.

DOB: 9-13-92

 

Treatment Plan Date

: 10-9-06

 

 

 

 

 

 

 

 

Other Agencies Involved:

Plan to Coordinate Services:

 

 

Jack Horner, M.D., Child

Phone contact during the first month of treatment, then as needed, but at least

Psychiatrist

1 time every 3 months.

 

 

 

 

 

Spring Hill Middle School

Request teacher to complete Achenbach teacher Report Form (TRF) 1 time

 

during the first month of treatment. Continued contact by phone as needed.

 

 

 

 

 

 

 

 

 

 

Medication(s):

Dose:

Frequency:

 

Indication:

Prozac

20 mg

1 x day

 

depression

 

 

 

 

 

 

 

 

 

 

1. Problem/Symptom: Depression as manifested by sadness, irritability, poor self-esteem, low energy, excessive sleep and suicidal ideation.

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 This will be measured by a t score of 60 or below on the YSR Withdrawn/Depressed scale at the time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.

 

 

 

 

 

 

 

Anticipated completion date:

4-2-07

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Short Term Goals/Objectives:

Date Established

Projected

Date Acheived

 

Completion Date

 

 

 

 

 

 

 

 

1. Jill and her father will develop a safety plan/no self-harm

10-9-06

10-9-06

10-9-06

 

contract

 

 

 

 

 

 

 

2. Jill will become involved in at least one additional

10-9-06

11-02-06

 

 

extracurricular activity or sport

 

 

 

 

 

 

 

3. Jill will report no suicidal ideation for 3 consecutive

10-9-06

12-02-06

 

 

weeks

 

 

 

 

 

 

 

 

 

 

 

4. Jill will learn coping skills, including problem solving and

10-9-06

1-16-07

 

 

emotional regulation. This will be measured by her

 

 

 

 

 

 

 

demonstrating these skills during therapy sessions and

 

 

 

 

 

bringing in homework assignments for two consecutive

 

 

 

 

 

weeks that show she practiced them between sessions.

 

 

 

 

 

5. Jill will learn to identify maladaptive, negative thoughts

10-9-06

4-02-07

 

 

and how to replace them with more positive, adaptive

 

 

 

 

 

 

 

thoughts. This will be measured by her demonstrating

 

 

 

 

 

these skills during therapy sessions and bringing in

 

 

 

 

 

homework assignments for two consecutive weeks that

 

 

 

 

 

show she practiced them between sessions.

 

 

 

 

 

 

 

 

 

 

 

 

 

Intervention/Action

 

Responsible Person(s)

 

1.

 

 

Individual therapy to help Jill learn and implement

 

 

 

Tom Thumb, Ph.D.

 

 

 

 

 

 

 

coping skills and to help her identify, process and

 

 

resolve feelings and concerns.

2.Jill Spratt

3.

 

 

 

 

 

 

Intervention/actions:

 

Responsible Person(s):

1.

Family Therapy to develop safety plan/no self harm

 

Tom Thumb, Ph.D.

 

 

contract, provide psycho-education about depression

 

 

2.

3.

to increase parents’ insight into Jill, and to increase

Jill Spratt

Jack and Joan Spratt, father and

parents’ ability to support and encourage Jill to utilize

 

step-mother

new coping skills.

 

 

 

Intervention/actions:

 

Responsible Person(s):

1.

Medication Management

 

Jack Horner, M.D.

 

 

 

 

 

 

 

2.

3.

 

 

 

 

Intervention/actions:

 

Responsible Person(s):

1.

 

 

 

 

 

 

2.

3.

 

 

 

 

 

 

 

 

Review Date:

Progress:

 

 

 

 

 

 

Review Date:

Progress:

 

 

 

 

 

 

2. Problem/Symptom: Family Conflict as manifested by poor communication between Jill and her father, rude comments towards her step-mother and frequent arguing between Jill and her step-mother. To establish a baseline, Mr. Spratt was asked to record for one week: 1) the number of times he attempted to talk to Jill about concerns and she was evasive or withdrew; and 2) the number of times Jill was rude to her step-mother or Jill and her step-mother argued. “Rude” behavior towards her step-mother included eye rolling; walking away while her step-mother tried to talk to her; using a hostile or sarcastic tone of voice; and making comments such as “you can’t tell me what to do, you’re not my parent.” Jill was evasive/withdrew from her father 8 times in one week and argued/was rude to her step-mother 26 times in one week.

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 step-mother to 7 times a week for 3 consecutive weeks; and family will report at least one positive interaction/family activity per day for 3 consecutive weeks.

Anticipated completion date: 4-2-07

Short Term Goals/Objectives:

Date Established

Projected

Date Achieved

 

Completion Date

 

 

 

 

1. Gather baseline data on evasive/withdrawn interactions

10-2-06

10-9-06

10-9-06

with father and arguing/rudeness with step-mother.

 

 

 

2. Family will establish routine times in the week for

10-9-06

10-23-06

 

communication and/or family activities (i.e., family meetings,

 

family fun nights). This will be measured by the family

 

 

 

establishing a schedule for communication/activities and

 

 

 

reporting the number of times each week that they followed

 

 

 

the schedule.

 

 

 

3. Jill and her father will learn communication and conflict

 

 

 

resolution skills. This will be measured by Jill and her father

10-9-06

 

11-23-06

 

demonstrating the skills, without coaching, to successfully

 

 

 

 

discuss and resolve issues in 2 consecutive family therapy

 

 

 

 

sessions.

 

 

 

 

 

 

4. Jill and her step-mother will learn communication and

10-9-06

 

12-23-06

 

conflict resolution skills. This will be measured by Jill

 

 

 

 

 

 

and her step-mother demonstrating the skills, without

 

 

 

 

coaching, to successfully discuss and resolve issues in

 

 

 

 

2 consecutive family therapy sessions.

 

 

 

 

 

5. Reduce evasive/withdrawn interactions with father to 3

10-9-06

 

1-23-07

 

times a week

 

 

 

 

 

 

 

 

 

 

6. Reduce arguing/rudeness to step-mother to 14 times a

10-9-06

 

2-23-07

 

week

 

 

 

 

 

 

 

 

 

 

7. Reduce evasive/withdrawn interactions with father to 1

10-9-06

 

3-9-07

 

time a week.

 

 

 

 

 

 

 

 

 

 

8. Reduce arguing/rudeness to step-mother to 7 times a

10-9-06

 

4-2-07

 

week.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intervention/actions:

 

Responsible Person(s):

1.

 

Family Therapy to explore and help family understand

.

 

Tom Thumb, Ph.D.

 

 

 

 

family dynamics, negative patterns and problems in

 

 

 

 

 

2.

 

3.

 

family structure; and to help family learn and use

 

 

Jill Spratt

 

Jack and Joan Spratt, father and step-

communication and conflict resolution skills.

 

 

mother

Intervention/actions:

 

Responsible Person(s):

1.

 

Individual Therapy to explore, process and resolve

 

 

Tom Thumb, Ph.D.

 

 

 

 

 

Jill’s feelings about family members, rules and

 

 

 

 

 

2.Jill Spratt

 

3.

 

structure; and to reinforce using good communication,

 

 

 

 

 

 

 

conflict resolution and coping skills at home.

 

 

 

 

 

Intervention/actions:

 

Responsible Person(s):

1.

 

 

 

 

 

 

 

 

 

2.

 

3.

 

 

 

 

 

 

Intervention/actions:

 

Responsible Person(s):

1.

 

 

 

 

 

 

 

 

 

2.

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Review Date:

Progress:

 

 

 

 

 

 

 

 

 

 

 

 

Review Date:

Progress:

 

 

 

 

 

 

 

 

 

 

 

 

Involvement of Family: Father and step-mother will participate in family therapy and follow through on homework assignments to improve family functioning. Father and step-mother will formally (behavior counts and homework assignments) and informally monitor Jill's symptoms, problems and progress. Father will support Jill in implementing new skills and becoming more active.

Services Needed beyond scope of organization or program:

Medication Management by Dr. Jack Horner

Estimated Completion date for level of care: 4-2-07

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