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PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN
PATIENT NAME: PATIENT ID # ADMISSION DATE:
AXIS
AXIS
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I: II:
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I: III:
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(if applicable)
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I: IV:
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Axis I co-occurring mental health disorder(if applicable) (if applicable)
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I: -----
V:
Axis I co-occurring mental health disorder(if applicable) (if applicable)
NAME and SIGNATURE OF RESPONSIBLE CLINICAL STAFF MEMBER:
By signing, I attest that I have participated with the treatment staff in the development of this treatment plan:
SIGNATURE OF PATIENT: DATE:
MULTI-DISCIPLINARY TEAM APPROVAL
SIGNATURE OF CASAC: DATE:
SIGNATURE OF QHP OTHER THAN CASAC: DATE:
SIGNATURE OF MEDICAL STAFF MEMBER: DATE:
NOTE: The individual treatment plan must be established within 30 days of admission. The individual treatment plan
is established upon review and approval by the Multi-Disciplinary Team.
SIGNATURE OF MEDICAL DIRECTOR/STAFF PHYSICIAN: DATE:
NOTE: If the physician has signed the individual treatment plan as part of the Multi-disciplinary Team, a second
physician signature is not required. Also, if the Physician’s signature is added separately and not as part of the Multi-
disciplinary Team it must be signed within 7 days of the Multi-disciplinary Team approval.
TA-7 - 822 (09/07)
Page 1 of 7
PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN (CONT’D)
Patient Name:
Patient ID #
Identified Functional Area – Chemical Use, Abuse and Dependence: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
Identified Functional Area – Social/Leisure/Activities of Daily Living: (Attach Additional Sheets, as necessary)
Goal (Attach Additional Sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
TA-7 - 822 (09/07)
Page 2 of 7
PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN (CONT’D)
Patient Name:
Patient ID #
Identified Functional Area – Vocational/Educational/Employment: (Attach additional Sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
Identified Functional Area – Family / Significant Other: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
TA-7 - 822 (09/07)
Page 3 of 7
PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN (CONT’D)
Patient Name:
Patient ID #
Identified Functional Area – Legal: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
Identified Functional Area – Medical / Physical Health: (Include any identified
needs based on the results
of the communicable
disease risk assessment):
Goal
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
TA-7 - 822 (09/07)
Page 4 of 7
PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN (CONT’D)
Patient Name:
Patient ID #
Identified Functional Area – Tobacco: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
Identified Functional Area – Mental Health and/or Emotional Health: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
TA-7 - 822 (09/07)
Page 5 of 7
PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN (CONT’D)
Patient Name:
Patient ID #
Identified Functional Area – Gambling: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
Identified Functional Area – Other: (Attach additional sheets, as necessary)
Goal (Attach additional sheets, as necessary)
Objectives Target Integrated Program of Therapies/Activities and
Date Schedules for Provision of Services
TA-7 - 822 (09/07)
Page 6 of 7
PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES
INDIVIDUAL TREATMENT PLAN (CONT’D)
Patient Name:
Patient ID #
Description and Nature of Additional Service/Referral: (Attach additional sheets, as necessary) Date/Time of Referral
Results of Referral: (Attach additional sheets, as necessary)
Procedures for Ongoing Coordination of Care: (Attach additional sheets, as necessary)
Description and Nature of Additional Service/Referral: (Attach additional sheets, as necessary) Date/Time of Referral
Results of Referral: (Attach additional sheets, as necessary)
Procedures for Ongoing Coordination of Care: (Attach additional sheets, as necessary)
Description and Nature of Additional Service/Referral: (Attach additional sheets, as necessary) Date/Time of Referral
Results of Referral: (Attach additional sheets, as necessary)
Procedures for Ongoing Coordination of Care: (Attach additional sheets, as necessary)
TA-7 - 822 (09/07)
Page 7 of 7
