Psychiatry
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Outpatient Mental Health Treatment Plan
Prepared by Robin Ukleya, LCSW, LPC (Therapist)

Client's Name: [textarea cols=80 rows=1]

Date of Initial Evaluation: [textarea cols=80 rows=1]

Diagnosis: [textarea cols=80 rows=5]

Primary Configuration: [select name="Q1" value="Individual|Couple|Family|Group"]

Frequency of Therapy: [select name="Q2" value="Weekly|Bi-weekly|Other"]

Expected Length of Treatment: [select name="Q3" value="12 to 16 Sessions (Approx. 3 to 4 Months)|17 to 32 Sessions (Approx. 5 to 8 Months)|33 to 48 Sessions (Approx. 9 to 12 Months)|More than 48 Sessions (12 months +)"]

Status of Problem/Focus of Treatment: [select name="Q4" value="New|Improved|Deteriorated|No Change|Problem Resolved"]

Risk Assessment
Previous/current suicidal ideations/attempts: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Client is currently assessed to be at [select value="no|low|moderate|high"] risk for self-harm as evidenced by client’s self-report of [select value="not having any|having a"] suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent: [textarea cols="20" rows="1" default="no action taken."]

Previous/current self-injurious behavior: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Client is currently assessed to be at [select value="no|low|moderate|high"] risk for self-injurious harm as evidenced by client’s self-report of [select value="not having any|having a"] self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent: [textarea cols="20" rows="1" default="no action taken."]

Previous/current homicidality/bodily injury towards others: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, no current plan or intent|current ideation and plan, no current intent|current ideation, plan, and intent"]. Client is currently assessed to be at [select value="no|low|moderate|high"] risk of being a harm to others as evidenced by client’s self-report of [select value="not having any|having a"] homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a homicidal ideation/plan/intent: [textarea cols="20" rows="1" default="no action taken."]

Additional information: [textarea cols="80" rows="3" default="no additional information."]

Reporting Concerns
Client currently endorses following symptoms: [checkbox name="variable_2" value="low mood|anhedonia|guilt|worthlessness| hopelessness|regret|decreased appetite| increased appetite|psychomotor retardation|suicidality|anxiety|aggressive behavior|impulsivity|difficulty with focus/ attention|irritability|panic attacks| agoraphobia|decreased need for sleep|obssessive-compulsive behaviors|withdrawn|difficulty sleeping|auditory hallucinations|visual hallucinations|thought broadcasting|thought insertion"]

Strengths: [checkbox value="Treatment responsiveness|Connectedness to others|Problem solving skills|Coping skills|Ability to adapt to change|A sense of purpose or meaning in life|Beliefs that discourage self-injury|Social skills|Anger management|Good health|Access to health care|Fear of risky behaviours and pain|Hope for the future—optimism|Sobriety|Medical compliance|A sense of the importance of health and wellness|Impulse control|Sense of self-worth or self-esteem|Sense of personal control or determination|Access to a variety of clinical interventions|Support for seeking help|Reasons for living|Married or a parent|Strong relationships with others|Opportunities to participate in and contribute to the world|A reasonably safe and stable environment|Restricted access to lethal means|Responsibilities and duties to others|Pets"]
Other Strengths: [textarea cols=80 rows=2]

Goals of the Treatment:
Goal 1 (Client Goal): [select value="none|reducing my fear(s)|having more pleasurable activities|improving communication with my spouse/children/friends/coworkers/others|expressing myself more assertively|learning how to relax
|better managing my health
|better tolerating my mistakes
|better tolerating others’ mistakes
|feeling less guilt
|feeling less depressed
|better accepting loss/death
|increasing my conversation skills
|learning how I come across to others
|not taking disappointment so hard
|doubting myself
|thinking more positively
|improving my sexual relationship
|controlling my eating or weight
|controlling my alcohol use
|changing my habit
|controlling my use of drugs
|better managing my pain
|learning how to improve my friendships
|reducing uncomfortable thoughts
|improving my sleep
|reducing my sensitivity to possible criticism
|talking out a pending decision
|learning problem-solving/decision making techniques
|worrying less
|learning more effective parenting skills
|reducing family difficulties
|reducing job difficulties
|better managing my temper
|taking initiative more often
|receiving medication help
|decreasing procrastinating
|better managing time
|decreasing trying to be perfect
|not reacting so emotionally
|allowing myself to express feelings more
|feeling more self-confident
|discussing my thoughts of harming myself
|discussing my thoughts of harming others
|adjusting better to a recent change or incident
|adjusting better to a past incident
|being more optimistic
|improving my self-awareness
|adopting a more health attitude"]

Goal 2 (Client Goal): [select value="none|reducing my fear(s)|having more pleasurable activities|improving communication with my spouse/children/friends/coworkers/others|expressing myself more assertively|learning how to relax
|better managing my health
|better tolerating my mistakes
|better tolerating others’ mistakes
|feeling less guilt
|feeling less depressed
|better accepting loss/death
|increasing my conversation skills
|learning how I come across to others
|not taking disappointment so hard
|doubting myself
|thinking more positively
|improving my sexual relationship
|controlling my eating or weight
|controlling my alcohol use
|changing my habit
|controlling my use of drugs
|better managing my pain
|learning how to improve my friendships
|reducing uncomfortable thoughts
|improving my sleep
|reducing my sensitivity to possible criticism
|talking out a pending decision
|learning problem-solving/decision making techniques
|worrying less
|learning more effective parenting skills
|reducing family difficulties
|reducing job difficulties
|better managing my temper
|taking initiative more often
|receiving medication help
|decreasing procrastinating
|better managing time
|decreasing trying to be perfect
|not reacting so emotionally
|allowing myself to express feelings more
|feeling more self-confident
|discussing my thoughts of harming myself
|discussing my thoughts of harming others
|adjusting better to a recent change or incident
|adjusting better to a past incident
|being more optimistic
|improving my self-awareness
|adopting a more health attitude"]

Goal 3 (Client Goal): [select value="none|reducing my fear(s)|having more pleasurable activities|improving communication with my spouse/children/friends/coworkers/others|expressing myself more assertively|learning how to relax
|better managing my health
|better tolerating my mistakes
|better tolerating others’ mistakes
|feeling less guilt
|feeling less depressed
|better accepting loss/death
|increasing my conversation skills
|learning how I come across to others
|not taking disappointment so hard
|doubting myself
|thinking more positively
|improving my sexual relationship
|controlling my eating or weight
|controlling my alcohol use
|changing my habit
|controlling my use of drugs
|better managing my pain
|learning how to improve my friendships
|reducing uncomfortable thoughts
|improving my sleep
|reducing my sensitivity to possible criticism
|talking out a pending decision
|learning problem-solving/decision making techniques
|worrying less
|learning more effective parenting skills
|reducing family difficulties
|reducing job difficulties
|better managing my temper
|taking initiative more often
|receiving medication help
|decreasing procrastinating
|better managing time
|decreasing trying to be perfect
|not reacting so emotionally
|allowing myself to express feelings more
|feeling more self-confident
|discussing my thoughts of harming myself
|discussing my thoughts of harming others
|adjusting better to a recent change or incident
|adjusting better to a past incident
|being more optimistic
|improving my self-awareness
|adopting a more health attitude"]

Objectives of the Treatment:
Objective 1: [select value="none|Reduce Depression-Behavioral activation, assess for unhealthy thinking and implement Cognitive Restructuring, increase social support, medication evaluation and compliance|Reduce Anxiety - Relaxation Training, PMR, Cognitive Restructuring, yoga, medication evaluation and compliance, exercise| Increase self esteem - Positive Asset Search, Perceived vs Ideal Self, try new things, increase socialization| Clarify and strengthen boundaries-Psychoeducation-Recommend Boundaries by Henry Cloud and John Townsend, assertiveness training|Improve self care-Self care assessment, daily shower, exercise, sleep hygiene, buy things for herself/himself|Eliminate substance abuse - Motivational Interviewing, participate in support group, AA, NA, etc.|Eliminate self harm or self injury-Stopping the Pain worksheets, MI, increase self-worth|Improve communication skills–Psychoeducation—Gottman materials, Assertiveness training, speaker-listener exercises, role playing in session|Increase Assertiveness-Increase communication training|Process grief and loss-Appointments with grief, journaling, sharing pictures, memories, etc., psychoeducational materials, recommend support groups|Reduce traumatic responses - Raise awareness of triggers, Relaxation training, exposure therapy, EMDR|Evaluate marital status (relationship status)-Sound Relationship house by Gottman, psychoeducation—recommend Gottman materials and classes; Evaluate pros and cons, psychoeduction on abusive relationships| Improve relationship with spouse–Psychoeducation--Gottman materials, Love Languages by Gary Chapman, date nights, Gottman Interventions, including Listening exercises, recovery from a fight, how to compromise|Improve sleep quality-Sleep hygiene habits including relaxation, hot bath or shower, no electronics, complete a sleep study, utilize CPap when required, medication compliance|Improve parenting skills-Love and Logic training, handouts, and more psychoeducation, Love Languages for children, Education on developmental stages"].

Objective 2: [select value="none|Reduce Depression-Behavioral activation, assess for unhealthy thinking and implement Cognitive Restructuring, increase social support, medication evaluation and compliance|Reduce Anxiety - Relaxation Training, PMR, Cognitive Restructuring, yoga, medication evaluation and compliance, exercise| Increase self esteem - Positive Asset Search, Perceived vs Ideal Self, try new things, increase socialization| Clarify and strengthen boundaries-Psychoeducation-Recommend Boundaries by Henry Cloud and John Townsend, assertiveness training|Improve self care-Self care assessment, daily shower, exercise, sleep hygiene, buy things for herself/himself|Eliminate substance abuse - Motivational Interviewing, participate in support group, AA, NA, etc.|Eliminate self harm or self injury-Stopping the Pain worksheets, MI, increase self-worth|Improve communication skills–Psychoeducation—Gottman materials, Assertiveness training, speaker-listener exercises, role playing in session|Increase Assertiveness-Increase communication training|Process grief and loss-Appointments with grief, journaling, sharing pictures, memories, etc., psychoeducational materials, recommend support groups|Reduce traumatic responses - Raise awareness of triggers, Relaxation training, exposure therapy, EMDR|Evaluate marital status (relationship status)-Sound Relationship house by Gottman, psychoeducation—recommend Gottman materials and classes; Evaluate pros and cons, psychoeduction on abusive relationships| Improve relationship with spouse–Psychoeducation--Gottman materials, Love Languages by Gary Chapman, date nights, Gottman Interventions, including Listening exercises, recovery from a fight, how to compromise|Improve sleep quality-Sleep hygiene habits including relaxation, hot bath or shower, no electronics, complete a sleep study, utilize CPap when required, medication compliance|Improve parenting skills-Love and Logic training, handouts, and more psychoeducation, Love Languages for children, Education on developmental stages"].

Objective 3: [select value="none|Reduce Depression-Behavioral activation, assess for unhealthy thinking and implement Cognitive Restructuring, increase social support, medication evaluation and compliance|Reduce Anxiety - Relaxation Training, PMR, Cognitive Restructuring, yoga, medication evaluation and compliance, exercise| Increase self esteem - Positive Asset Search, Perceived vs Ideal Self, try new things, increase socialization| Clarify and strengthen boundaries-Psychoeducation-Recommend Boundaries by Henry Cloud and John Townsend, assertiveness training|Improve self care-Self care assessment, daily shower, exercise, sleep hygiene, buy things for herself/himself|Eliminate substance abuse - Motivational Interviewing, participate in support group, AA, NA, etc.|Eliminate self harm or self injury-Stopping the Pain worksheets, MI, increase self-worth|Improve communication skills–Psychoeducation—Gottman materials, Assertiveness training, speaker-listener exercises, role playing in session|Increase Assertiveness-Increase communication training|Process grief and loss-Appointments with grief, journaling, sharing pictures, memories, etc., psychoeducational materials, recommend support groups|Reduce traumatic responses - Raise awareness of triggers, Relaxation training, exposure therapy, EMDR|Evaluate marital status (relationship status)-Sound Relationship house by Gottman, psychoeducation—recommend Gottman materials and classes; Evaluate pros and cons, psychoeduction on abusive relationships| Improve relationship with spouse–Psychoeducation--Gottman materials, Love Languages by Gary Chapman, date nights, Gottman Interventions, including Listening exercises, recovery from a fight, how to compromise|Improve sleep quality-Sleep hygiene habits including relaxation, hot bath or shower, no electronics, complete a sleep study, utilize CPap when required, medication compliance|Improve parenting skills-Love and Logic training, handouts, and more psychoeducation, Love Languages for children, Education on developmental stages"].

□ I have discussed the information listed above, various treatment strategies, and their possible outcomes with client and/or parent/guardian. He/She/They concur with the above diagnosis and treatment plan.

Our signatures below mean that we have participated in the formulation of this treatment plan, understand and approve of it, and accept the responsibility to carry out our parts of the plan fully.

Signature of Client ___________________________________________
Date ________________

Signature of Client's Authorized Representative _____________________________________
Date ________________

Signature of Therapist/Counselor ___________________________________________
Date ________________
Outpatient Mental Health Treatment Plan
Prepared by Robin Ukleya, LCSW, LPC (Therapist)

Client's Name:

Date of Initial Evaluation:

Diagnosis:

Primary Configuration:

Frequency of Therapy:

Expected Length of Treatment:

Status of Problem/Focus of Treatment:

Risk Assessment
Previous/current suicidal ideations/attempts: . Client is currently assessed to be at risk for self-harm as evidenced by client’s self-report of suicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent:

Previous/current self-injurious behavior: . Client is currently assessed to be at risk for self-injurious harm as evidenced by client’s self-report of self-injurious ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a suicidal ideation/plan/intent:

Previous/current homicidality/bodily injury towards others: . Client is currently assessed to be at risk of being a harm to others as evidenced by client’s self-report of homicidal ideation, and/or plan, and/or intent based upon today's exam. The following action was taken as a result of client having a homicidal ideation/plan/intent:

Additional information:

Reporting Concerns
Client currently endorses following symptoms:

Strengths:
Other Strengths:

Goals of the Treatment:
Goal 1 (Client Goal):

Goal 2 (Client Goal):

Goal 3 (Client Goal):

Objectives of the Treatment:
Objective 1: .

Objective 2: .

Objective 3: .

□ I have discussed the information listed above, various treatment strategies, and their possible outcomes with client and/or parent/guardian. He/She/They concur with the above diagnosis and treatment plan.

Our signatures below mean that we have participated in the formulation of this treatment plan, understand and approve of it, and accept the responsibility to carry out our parts of the plan fully.

Signature of Client ___________________________________________
Date ________________

Signature of Client's Authorized Representative _____________________________________
Date ________________

Signature of Therapist/Counselor ___________________________________________
Date ________________

Result - Copy and paste this output: