Treatment Plan Template
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2006 Treatment Plan Template
Treatment Plan Template
Participant Name
SSN #
Healthy Connections Physician:
MEDICAID #
Healthy Connection #
CAFAS Score #
Provider Agency completing the Service Plan:
DATE OF AMENDMENT (if applicable):
Comment (What is being amended and why):
DATE OF PLAN:
120 Day Rev.
240 Day Rev.
Annual Update:
(P)= Principal Diagnosis
DIAGNOSTIC SUMMARY
(check if applicable):
Severe Emotional Disturbance
Severe and Persistent Mental Illness
Axis I :
Axis II :
Axis III :
Axis IV :
Axis V :
Current GAF
Highest Past GAF
Duration of Principal Diagnosis
Functional Areas Identified as Deficits in the Assessment
(See IDAPA 16.03.10.113)
Less than one year
Health/Medical
Social/interpersonal
Housing
One to two years
Vocational/Educational
Family
Community/Legal
More than two years
Financial
Basic Living Skills
Expected
Functional Area I:
Type, freq
End Date
& hrs
Issue I:
I.A.
Goal I:
Objective I.A.
(concrete and measurable and include time frames for completion)
Task I.A.1.
(Specific, time-limited activities)
Task I.A.2.
(Specific, time-limited activities)
Expected
Type, freq
Functional Area II:
End Date
& hrs
Issue II:
II.A.
Goal II:
Objective II.A.
(concrete and measurable and include time frames for completion)
Task II.A.1.
(Specific, time-limited activities)
Task II.A.2.
(Specific, time-limited activities)
Expected
Type, freq
Functional Area III:
End Date
& hrs
Issue III:
III.A.
Goal III:
Objective III.A
. (concrete and measurable and include time frames for completion)
Task III.A.1.
(Specific, time-limited activities)
Task III.A.2.
(Specific, time-limited activities)
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