Sample Individual Treatment Plan (Page 6 of 7) in pdf

Sample Individual Treatment Plan Page 6

Referral (s) will be made to (if needed):

Person (s) responsible for making referral (s):

Time Frame

ABC Work support group

Rebecca (DRS Counselor)

Coordination of Services – identify other services recipient is receiving and explain how the services are being coordinated):

Rule 79 Case Manager Mark __________, is coordinating services, XYZ CSP, Rebecca ________ of DRS.

This plan was developed with the participation of the recipient or legal representative (Identify):

Yes___

No____ (Specify reason): ______________________________________________________________________________________________

Signatures:

_______________________________________________/_______________

Recipient

Date

_______________________________________________________ /___________________

Recipient’s Legal Guardian (if applicable)

Date

________________________________________________________ /___________________

Mental Health Professional

Date

Or Mental Health Practitioner (individual who wrote plan)

________________________________________________________ /___________________

Mental Health Professional

Date

(Individual providing clinical supervision in the development of the plan and determination of medical necessity)

_________________________________________________________/___________________

Other

Date

Sample Individual Treatment Plan Page 6