Critical Elements of a
Person-centered Treatment Plan
Checklist
Values and Areas of Interest (Things that are important to me)
ü Hopes: “I want to live on my own”
ü Dreams: “I used to dream about getting married and having children”
ü Interests: “I like to listen to music”
ü Values: “Family”
Life Beyond Services: Discharge Criteria (How I will know that I don’t need services anymore)
ü Stated in the plan
ü Shared with individual, family members, relevant supports
ü What would need to change so I can manage on my own?
ü Expresses hope for life beyond services
ü Transition process to other levels of support
Strengths
ü Skills: “operating cash register, expressing feelings, balancing checkbooks, bilingual”
ü Qualities: “hard working”
ü Experiences: “survived many hardships when homeless and in prison”
ü Supports: “my neighbors”
Personal and Community Supports (That can help me achieve my goals)
ü People: coffee shop owner, neighbor, therapist
ü Places: coffee shop, museum
ü Activities: volunteering at the museum, reading mythology
ü Things: my music selection
Possible Barriers (Things that could prevent me from achieving these goals)
ü Internal: “fear of people judging me”, “beliefs that people are trying to hurt me”
ü External: “application process too confusing”
Goal Statements (What I want my life to be like)
ü Expressed in person’s own words and primary language
ü Provides a focus of engagement/life changes as a result of treatment
ü Consistent with a desire for recovery, self-determination and self-management
ü Reflective of a person’s values, lifestyle, culture, age, strengths and preferences
ü Written in positive terms
Objectives
ü Milestones or way-posts towards goals
ü Sometimes considered “short-term” goals
ü Identifies the immediate focus of services
ü Focuses on removal or overcoming of barriers
ü Typically about action, not change in thinking, understanding or insight
ü Focuses on behaviors resulting from changes in understanding or knowledge
Interventions (who, what, where, when, why, & how often or how much)
ü Describes the modality or type of activity
ü Identifies who is responsible for the activity
ü Specifies the frequency, intensity and duration of the intervention
ü Specifies the location, if necessary
ü States the purpose, intent or impact of the intervention in support of objective
ü Establishes medical necessity
Opportunities for Documentation of Updates
to Assessments, Plan or Crisis Plan
ü When each service is provided
ü Target dates specified in the objective
ü Intervals specified by licensure, certification, accreditation, policy or payer
ü Transition or discharge
Crisis Prevention Plan
ü Wellness Recovery Action Plan
ü Advance Directives
ü Health Care Proxy
ü Written instructions through Living Will
ü Do Not Resuscitate Orders
ü Organ Donation
Signature Page for Supports
ü Use of natural supports
ü Responsible parties for providing interventions/services listed in plan
ü Approval of plan by person receiving services