typing assignment

Name of Individual:

(Preferred Name):      

DOB:

Medicaid ID:      

Person’s Address:

(Street/mailing address)

(City/State/Zip)

Telephone #:

(Home) ( )

Axis I

All Current Medications

(* Update and revise list of medications anytime there is a change.)

Dose:

Frequency:

1.

2.      

3.      

4.      

List all Known Allergies: (*Update and revise list of allergies anytime there is a change).

1.

3.      

2.      

4.      

SUMMARY OF COMPREHENSIVE ASSESSMENT: (What brought the consumer to United Counseling Services)

INDIVIDUAL’S FUNCTIONAL STRENGTHS & WEAKNESSES:

LONG RANGE DESIRED OUTCOME:

SERVICE DELIVERY

FREQUENCY

TOTAL HOURS

PROJECTED DISCHARGE/LENGTH OF SERVICE

MHSS

3-5 times a week

15 hours weekly

6 months

GOAL 1:

BEHAVIOR DATA :

OBJECTIVE 1:

Target Date:

INTERVENTION:

Person Responsible:

Frequency:

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

OBJECTIVE 2:

Target Date:

INTERVENTION:

Person Responsible:

Frequency:

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

Status Codes: N=New, R=Revised, O=Ongoing, A=Achieved, D=Discontinued

GOAL 2:

BEHAVIOR DATA :

OBJECTIVE 1:

Target Date:

INTERVENTION:

Person Responsible:

Frequency:

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

OBJECTIVE 2:

Target Date:

INTERVENTION:

Person Responsible:

Frequency:

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

Status Codes: N=New, R=Revised, O=Ongoing, A=Achieved, D=Discontinued

GOAL 3:

BEHAVIOR DATA:

OBJECTIVE 1:

Target Date:

INTERVENTION:

Person Responsible:

Frequency:

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

OBJECTIVE 2:

Target Date:

INTERVENTION:

Person Responsible:

Frequency:

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

Status Codes: N=New, R=Revised, O=Ongoing, A=Achieved, D=Discontinued

GOAL 4: Safety Plan

BEHAVIOR DATA: The consumer is taking psychotropic medication and is able to identify the purpose of all of his/her medication as well as the side effect. The consumer will develop a safety p plan and take preventative measures to avoid falling or seriously injuring himself/herself

OBJECTIVE 1:

Target Date:

Consumer will identify 2 skills to assist him/her with reducing/eliminating the risks of falling.

INTERVENTION:

Person Responsible:

Frequency:

Case Manager will assist consumer with making a list of prescriptions and over the count medications. Case Manager will encourage him/her to identify how many times, if any, he/she has fallen as well as the conditions that could cause him/her to fall.

Name of Case Manager and Credentials

Review Date:

Status Code:

Progress toward objective:

N

Status Codes: N=New, R=Revised, O=Ongoing, A=Achieved, D=Discontinued

GOAL 5: Individualized Discharge Plan

Status of consumer towards discharge: (Please select one)

Presenting Condition greatly improved

Presenting Condition moderately improved

Presenting Condition slightly improved

Presenting Condition not improved

Presenting Condition has worsened

Discharge Update: Please include recommended support systems and services that will support recovery and/or well-being.

Specific Discharge Needs: Please include Strengths, Needs, Abilities and Preferences as a result in program participation.

Significant event(s) that may create increased stress and trigger the onset of a crisis . (Examples include: Anniversaries, holidays, noise, change in routine, and inability to express medical problems or to get needs met, etc. Describe what one may observe when the person goes into crisis. Include lessons learned from previous crisis events):

Crisis prevention and early intervention strategies that were effective. (List everything that can be done to help this person AVOID a crisis. What worked in the past):

Describe the back-up protocols to support the individual . (Who should be called and when during a crisis? How can they be reached? Include contact names, phone numbers, hours of operation, etc. Be as specific as possible.)

Specific recommendations for interacting with the person receiving a Crisis Service: (Are they techniques that work for calming the consumer down?)

Safety Plan: Identify and address possible risks, including fall risk plan (if needed).

Did previous Fall Risk Assessment require a Safety Plan? □ Yes □ No

Potential Risks to consumer:

Prevention methods:     

I. PERSON RECEIVING SERVICES

· I confirm and agree with my involvement in the development of this ISP. My signature means that I agree with the services/supports to be provided.

· I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for my plan.

Signature:       ____________ Date:   /  /    

(Required when person is his/her own legal guardian)

II. PERSON RESPONSIBLE FOR THE ISP:

· The following signature confirms the responsibility of the QMHP/LP for the development of this ISP. The signature indicates agreement with the services/supports to be provided

Signature:       ____________ Date:   /  /    

(Required when person is his/her own legal guardian)

IV. SUPERVISOR REVIEW OF ISP:

· The following signature confirms that ISP has been reviewed and approved by a clinical supervisor. The signature indicates agreement with the services/supports to be provided.

Signature:       ____________ Date:   /  /    

(Required when person is his/her own legal guardian)