Template Treatment Plan – Fill Out and Use

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

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:

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: