2013 Individual Plan Of Care (Ipoc) / Individual Treatment Plan Template Page 2
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2Individual Plan of Care (IPOC) / Individual Treatment Plan
Client Name (Last, First, MI):
ID #:
Medicaid #:
(continued)
3. Proposed Treatment Process:
Based on master problem list, identify specific goals/objectives to address the problem(s). Each goal should be
accompanied by measurable objectives leading to attainment of goal(s).
a. Date
b. Type of
c. Units
d. Days per
e. Goals/measurable objectives/criteria for
f. Target
Service
Service
per Day
Week
achievement
Expected
(select
from appropriate
Ordered
Persons responsible for service delivery
Achievement
drop-down menu)
Date
Discrete
Bundled
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
a)
b)
4. Client Signature: Signature indicates patient agreement with and participation in
Date:
development of this plan, and receipt of a copy.
5. Parent or Guardian Signature (as appropriate):
Date:
6. When applicable, list names of family members and/or friends who participated in the development of this plan:
Family Member / Friend Name:
Relationship:
Date:
Family Member / Friend Name:
Relationship:
Date:
Agency Name:
Medicaid Provider
Phone:
Fax:
ID:
Clinician Signature, Title, and Date:
IPOC 1/13
Page 2 of 2
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