Family Therapy Treatment Plan Template by efi69415

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									                                      SAMPLE FORM
             Below is a sample Medicaid compliant Individualized Treatment Plan form


                INDIVIDUAL TREATMENT PLAN (ITP)

                     Client Name                                        ITP Date




Diagnosis
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V CGAS/GAF/Other:


               PART 132 MENTAL HEALTH SERVICES TO BE PROVIDED


                                                Amount of Frequency       Duration        Staff
    Medicaid Service Type            Goal(s)
                                                 Service  of Service     of Service    Responsible

                                                                                       (must be by
                                                 (i.e. 30      (i.e.       (i.e. 6    name or title of
                                                 minutes)    2x/week)     months)      one specific
                                                                                         person)
Psychiatric Evaluation
Psychotropic Medication Admin.
Psychotropic Medication Monitoring
Psychotropic Med Training
Individual Therapy/Counseling
Group Therapy/Counseling
Family Therapy/Counseling
Community Support Residential –
Individual
Community Support Residential –
Group
Community Support – Individual
Community Support – Group
CM – Client-Centered Consultation
CM– Mental Health
CM–Transition Linkage & Aftercare

ITP Sample Form – Rev. July, 2008
              PART 132 MENTAL HEALTH SERVICES TO BE PROVIDED
GOAL #1:

OBJECTIVES:




GOAL #2:


OBJECTIVES:




GOAL #3:


OBJECTIVES:




GOAL #4:


OBJECTIVES:




ITP Sample Form – Rev. July, 2008
                        INDIVIDUAL TREATMENT PLAN (ITP)
                        Client and/or Guardian Signature Page

CLIENT (required for all clients 12 years of age or older)
I have participated in the planning process for this treatment plan. The process for development, review,
and modification of the treatment plan contents has been explained to me in a language that I
understand. I understand the risks and benefits of these services. I agree and consent to receive services
as outlined in this plan. I have been given a copy of this treatment plan.




Client Signature                                                    Date

        Client refused to sign ITP Date: _________ (Client record must contain progress note
        documenting client’s refusal)

        Copy clinically contraindicated (explain):




GUARDIAN (required for all clients under the age of 18 unless emancipated minor and 18 years
of age or older if adjudicated legally disabled)

I have participated in the planning process for this treatment plan. The process for development, review,
and modification of the treatment plan contents has been explained to me in a language that I
understand. I understand the risks and benefits of these services. I agree and consent to the services as
outlined in this plan. I have been given a copy of this treatment plan.




Legal Guardian Signature                                            Date


        Notified of need for signature               Date: __________

        Legal Guardian refused to sign ITP           Date: __________ (Client record must contain progress
        note documenting guardian’s refusal)




ITP Sample Form – Rev. July, 2008
                         INDIVIDUAL TREATMENT PLAN (ITP)
                                Staff Signature Page

STAFF RESPONSIBLE FOR ITP DEVELOPMENT, REVIEW, AND MODIFICATION
Name/Signature                                                       Title                      Date

                                                            QMHP                  LPHA

                                                            QMHP                  LPHA




STAFF RESPONSIBLE FOR EXPLANATION OF ITP PROCESS
I have explained the process for development, review, and modification of the treatment plan contents to
the client, parent/guardian, and other persons of the client’s choosing in a language that they understand.

Name/Signature                                            Date




STAFF PARTICIPATING IN ITP DEVELOPMENT, REVIEW, AND MODIFICATION
Name/Signature                                                           Title                      Date
                                                           MHP               QMHP        LPHA

                                                           MHP               QMHP        LPHA

                                                           MHP               QMHP        LPHA




CLINICAL APPROVAL
Name/Signature                                                                Title             Date
                                                                                 LPHA


Comments:




ITP Sample Form – Rev. July, 2008

								
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