TREATMENT PLAN
ADMITTING DIAGNOSES [From psychiatric evaluation, if available]
Axis I:
1. __296.32 Major Depressive Disorder, Recurrent, Moderate
Axis III:
1. __Deferred to appropriate specialty_____________________
2. __309.81 Posttraumatic stress disorder (provisional)_______
2. ________________________________________________________
3. ________________________________________________________
3. ________________________________________________________
Axis II:
1. __799.90 Diagnosis deferred_____________________________
Axis IV: ___No obvious current psychosocial stressors______
2. ________________________________________________________
Axis V: Current G.A.F. _55___ Highest G.A.F. in last year __65______
Prognosis: []Good [x]Fair []Guarded []Poor
Estimated Date of Discharge: ____9-15-02______________
Plan Date: ___1-15-02_________
Assessment elements reviewed: [x}psychosocial [x]medical history []psychiatric assessment []________________________________________
Clinician’s integration of assessment findings:
Key Findings:
1. Complaints of depressed mood for two months.
2. Intrusive recollection of previous trauma.
3. Passive suicidal wishes.
Background:
1. Father committed suicide when client was three.
2. Sexually molested at twelve.
3. Pattern of conflicted relationships with multiple male partners.
4. Three previous episodes of treatment for depression.
Formulation:
1. Genetic predisposition for depression.
2. Had little role modeling for effective relationships with men.
3. Unresolved feelings over molestation.
4. Poor coping skills in general.
Plan:
1. Counseling to help resolve feelings and teach coping skills.
2. Referral to AMAC.
3. Refer for psychiatric evaluation.
Prioritized Problem List:
1. Suicidal wishes
2. Depressed mood
3. Intrusive ideation
4. ___________________________________
Discharge Criteria:
1. The client will report absence of suicidal wishes for three months.
2. The client will report adequate restful sleep 22 or more days per month for three months.
3. The client will report intrusive ideation less than twice per week for eight weeks.
4. ________________________________________________________________________
Strengths to be used in developing treatment plan:
Limitations – Special Needs – Barriers to Learning
[x]acknowledges illness [x]verbalizes desire for treatment
[x]self-reflective [x]insightful [x]able to read [x]able to problem-solve
[x]follows directions []accepts responsibility for choices
[]support system in place
Other: familiar with treatment procedures; knows she is a survivor
__________________________________________________________
[]denies illness []in treatment under duress []denies responsibility for self
[]hearing impaired []vision impaired []mobility impaired []health problems
[]reading difficulty []primary language other than English ____________
[x]lacks support system []cognitive limitations [x]emotional limitations
Other: discouraged by recurrence of symptoms and apparent
intractability of problems
_________________________________________________________
NAME: _____Yu__________________Itcudbe______________________________
LAST,
FIRST
MIDDLE
CLIENT NO. ____99999_______________
GOAL
Target Date
9-15-02
The client will report that she has had no suicidal wishes for three consecutive months.
Objective(s)
1. The client will keep a daily journal and review it with the counselor at each meeting.
2. The client will identify three primary sources of distress and demonstrate at least one
coping strategy for each.
GOAL
The client will report adequate restful sleep for 14 consecutive nights.
Objective(s)
1. The client will prepare a personal good sleep habit plan.
2. The client will follow her good sleep habit plan every night, including weekends.
3. The client will document her sleep patterns in her daily journal.
GOAL
The client will report intrusive ideation less than twice per week for one month.
Objective(s)
1. The client will demonstrate thought stopping skills in session.
2. The client will practice thought stopping skills each time she has intrusive thoughts.
begin 1-15-02
and continue
through
treatment
9-15-02
Target Date
4-15-02
1-31-02
3-28-02
begin 1-31-01
and continue
through
treatment
Target Date
5-15-02
2-15-02
begin 2-15-02
and continue
through
treatment
begin 2-15-02
and continue
through
treatment
Target Date
3. The client will document her intrusive thoughts and thought stopping skills in her journal.
GOAL
Date Resolved
Date Resolved
Date Resolved
Date Resolved
Objective(s)
FROM
TO
1-15-02
4-15-02
TYPE OF SERVICE (individual, group,
medication, case management)
Individual counseling
FREQUENCY
AMOUNT of TIME
CONTACT
weekly
50 minutes
R. Goode, LCSW
Treatment Plan Reviewed By _______________________________________________________Client
Date: _________________________
Treatment Plan Reviewed By _______________________________________________________Staff
Date: _________________________
Treatment Plan Reviewed By _______________________________________________________C.M.
Date: _________________________
Treatment Plan Reviewed By _______________________________________________________ M.D.
Date: _________________________
Six month review by ______________________________________________________________ M.D.
Date: _________________________
NAME: _______Yu_____________________Itcudbe_________________________________
LAST,
FIRST
MIDDLE
CLIENT NO. ________________________