Sample Treatment Plan
Recipient Information Medicaid Number:12345678 Name: Jill Spratt DOB: 9-13-92 Other Agencies Involved: Jack Horner, M.D., Child Psychiatrist Spring Hill Middle School Provider Information Medicaid Number:987654321 Name: Tom Thumb, Ph.D. Treatment Plan Date: 10-9-06 Plan to Coordinate Services: Phone contact during the first month of treatment, then as needed, but at least 1 time every 3 months. Request teacher to complete Achenbach teacher Report Form (TRF) 1 time during the first month of treatment. Continued contact by phone as needed.
Dose: 20 mg
Frequency: 1 x day
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 This will be measured by a t score of 60 or below on the YSR Withdrawn/Depressed scale at the time of discharge.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: 1. Jill and her father will develop a safety plan/no self-harm contract 2. Jill will become involved in at least one additional extracurricular activity or sport 3. Jill will report no suicidal ideation for 3 consecutive weeks 4. Jill will learn coping skills, including problem solving and 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 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. Date Established Projected Completion Date Date Acheived
10-9-06 10-9-06 10-9-06 10-9-06
10-9-06 11-02-06 12-02-06 1-16-07
Intervention/Action Individual therapy to help Jill learn and implement
1. Tom Thumb, Ph.D.
coping skills and to help her identify, process and resolve feelings and concerns. Intervention/actions: Family Therapy to develop safety plan/no self harm contract, provide psycho-education about depression to increase parents’ insight into Jill, and to increase parents’ ability to support and encourage Jill to utilize new coping skills. Intervention/actions: Medication Management
3. 1. Tom Thumb, Ph.D. 3. Jack and Joan Spratt, father and step-mother 1.
2. Jill Spratt
Responsible Person(s): Jack Horner, M.D.
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...