Intervention only

DATE: TIME IN: TIME OUT: UNITS: LOCATION:

Goal: Michelle desires to manage both her mental and physical health 70% of the time.

O: Michelle agrees to attempt to verbalize the need to take psychotropic medication and to take medication as prescribed daily.

O: Michelle agrees to attend all scheduled appointments with no more than 1 missed/rescheduled appointment per quarter.

O: Michelle agrees to develop techniques to manage depressive symptoms 4 out of 7 days a week.

O: Michelle agrees to increase positive interactions with her primary support system by decreasing incidents to no more than 3 per week.

O: Michelle agrees to create a safety plan for the family and review monthly.

O: Michelle agrees to increase physical activity to 2 times per week

Goal: Michelle desires to demonstrate the ability to complete daily living skills 100% of the time.

O: Michelle agrees to cook meals for her family 3 times a week.

O: Michelle desires to create a monthly budget and update weekly.

O: Michelle agrees to access 1 community/socialization resource monthly.

O: Micelle agrees to explore at least 1 housing resource monthly.

Skill-Building Interventions (using domains identified in needs assessment):

I1:

I2:

I3:

Assessment of Progress towards Skill Objectives:

A1:

A2:

A3:

Significant Observations/Significant Incidents:

Contact with Others:

Staff Signature and Credentials: Date: