Treatment Plan Template Page 2
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2006 Treatment Plan Template
Expected
Type, freq
Functional Area IV:
End Date
& hrs
Issue IV:
IV.A.
Goal IV:
Objective IV.A.
(concrete and measurable and include time frames for completion)
Task IV.A.1.
(Specific, time-limited activities)
Task IV.A.2.
(Specific, time-limited activities)
Expected
Functional Area V:
Type, freq
End Date
& hrs
Issue V:
V.A.
Goal V:
Objective V.A.
(concrete and measurable and include time frames for completion)
Task V.A.1.
(Specific, time-limited activities)
Task V.A.2.
(Specific, time-limited activities)
Expected
Type, freq
Functional Area VI:
End Date
& hrs
Issue VI:
VI.A.
Goal VI:
Objective VI.A.
(concrete and measurable and include time frames for completion)
Task VI.A.1.
(Specific, time-limited activities)
Task VI.A.2.
(Specific, time-limited activities)
SIGNATURES OF PARTICIPANTS IN DEVELOPING THE TREATMENT PLAN
I have been informed that I have a choice of Providers. My choices of Provider(s) are:
I participated in the development of this Treatment Plan, have received a copy, and I agree to its content.
I give my consent for information exchange among the MHA and the service provider(s) as necessary for my care and treatment
until this plan is amended or for one year, whichever comes first.
Participant/Guardian:
Date:
Mental Health Professional:
Date:
Other:
Date:
I reviewed this participant's plan and record, and indicate that the provision of Mental Health Services, specifically,
______________________________________________________________________________________________ is medically necessary.
Physician Signature:
Date:
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