Nicohwilliam

TREATMENT PLAN

CONFIDENTIAL

Every 90 days update this form or update when Diagnosis changes

THERAPIST INFORMATION

Therapist Name		Date
Telephone	575-393-0692	Fax	575-393-0796

Patient Information

Patient Name		Member ID Or PACTS #
Date of Birth		Gender		Health Plan
Current Identified Problem(s)

Functioning

Please assess how current symptoms have affected the level of impairment in the following categories:

Categories	Impairment Level (Circle One)
Relationship	None	Mild	Moderate	Severe
	0	1	2	3
Job/School Performance	0	1	2	3
Social	0	1	2	3
Physical Health	0	1	2	3
Activities of Daily Living (hygiene, bathing, etc.)	0	1	2	3
Eating Habits	0	1	2	3

Risk Assessment (check all that apply)

Factor	Not Present	Ideation	Plan	Means	Prior Attempt	Date
Suicidality
Homicidality

Concurrent S/A	Alcohol	Marijuana	Stimulants	Opiates	Other

Diagnostic Information

	ICD-10 CODE	DESCRIPTION
PRIMARY DIAGNOSIS
SECONDARY DIAGNOSIS
PSYCHO SOCIAL FACTORS
CONTEXTUAL FACTORS
V/Z CODES

Treatment Plan, Frequency, and Duration

Date First Seen		Date of Last session
Service Requested		Frequency

Treatment Goals

List goals directed at reducing risk and impairment to functioning as reported on page 1.

Use Progress Rating Scale, below, when addressing Methods for Achieving Goals.

Progress Rating Scale

1= Much Worse 3= No change 5= Great Improvement

2= Somewhat Worse 4= Slight Improvement 6= Resolved

Problems/Diagnosis	Measurable Behavioral Goals
1.		A
2.		B
3.		C

Methods for Achieving Goal #A
Progress Since Last Report (Progress Rating # )

Methods for Achieving Goal #B
Progress Since Last Report (Progress Rating # )

Methods for Achieving Goal #C
Progress Since Last Report (Progress Rating #)

Discharge Criteria ( specific and measurable)
Additional Comments

Client Signature		Date
Counselor Signature		Date

Revised 02/2016 laptop/2016 THERAPIST FORMS\Treatment plan.doc