TREATMENT PLAN

ADMITTING DIAGNOSES [From psychiatric evaluation, if available]

Axis I:
1. __296.32 Major Depressive Disorder, Recurrent, Moderate
2. __309.81 Posttraumatic stress disorder (provisional)______
3. ______/ Axis III:
1. __Deferred to appropriate specialty______
2. ______
3. ______
Axis II:
1. __799.90 Diagnosis deferred______
2. ______/ Axis IV: ___No obvious current psychosocial stressors______
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.
  1. Pattern of conflicted relationships with multiple male partners.
  2. 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:
[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
______/ Limitations – Special Needs – Barriers to Learning
[]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______CLIENT NO. ____99999______
LAST,FIRSTMIDDLE

GOAL

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. /

Target Date

9-15-02
begin 1-15-02 and continue through treatment
9-15-02 /

Date Resolved

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.
/

Target Date

4-15-02
1-31-02
3-28-02
begin 1-31-01 and continue through treatment /

Date Resolved

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.
3. The client will document her intrusive thoughts and thought stopping skills in her journal. /

Target Date

5-15-02
2-15-02
begin 2-15-02 and continue through treatment
begin 2-15-02
and continue through treatment /

Date Resolved

GOAL

Objective(s) /

Target Date

/

Date Resolved

FROM

/ TO / TYPE OF SERVICE(individual, group, medication, case management) / FREQUENCY / AMOUNT of TIME / CONTACT

1-15-02

/ 4-15-02 / Individual counseling / 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______CLIENT NO. ______
LAST,FIRSTMIDDLE