This is a fictitious case. All names used in the document are fictitious.

Sample Treatment Plan Update Recipient Information Provider Information Medicaid Number:123456789 Medicaid Number:987654321 Name: Jill Spratt Name: Tom Thumb, Ph.D. DOB: 9-13-92 Treatment Plan Date: 10-9-06 Treatment Plan Review Date: 3-19-07 Other Agencies Involved: Plan to Coordinate Services: Jack Horner, M.D., Child Psychiatrist

As needed, but at least 1 time every 3 months.

Spring Hill Middle School Contact by phone as needed.

Diagnoses: Axis I: 296.25 Major Depressive Disorder, Single Episode, in Partial Remission V61.20 Parent-Child Relational Problem Axis II: No diagnosis Axis III: No diagnosis Axis IV: Problems with Primary Support Group Axis V: 61 Justification for Diagnosis Change: Primary diagnosis has been changed from Major Depressive Disorder, Single Episode, Moderate, to Major Depressive Disorder, Single Episode, in Partial Remission to reflect the progress Jill has made. The diagnosis was changed to partial remission because although she exhibited enough symptoms for a Major Depressive Disorder diagnosis at the beginning of treatment, currently she is only experiencing feelings of worthlessness; and depressed and irritable mood, and these symptoms are milder than they were at the start of treatment. Medication(s): Dose: Frequency: Indication: Prozac 20 mg 1 x day depression Response to Medication and other Concurrent Treatment: Jill has responded well to Prozac. Jill reports that she feels the medication has helped her and her father also reports seeing improvement after Jill started medication. In a recent phone contact on (3-12-07) Dr. Horner indicated that he plans to continue Jill on her current dose of Prozac. There are no other concurrent treatments. 1. Problem/Symptom: Current symptoms of depression include periods of sadness, irritability and poor self- esteem. In addition, over the past few months Jill has had difficulty coping with stressors; she has reacted to stressors with a brief increase in depressive symptoms, including increased sleep, suicidal thoughts, and loss of interests. Long Term Goal: Symptoms of depression will be significantly reduced and will no longer interfere with Jill’s functioning. This will be measured by a t score of 60 or below on the YSR at the time of discharge. Anticipated completion date: 6-4-07 Short Term Goals/Objectives:

1. Jill and her father will develop a safety plan/no self-harm contract

2. Jill will become involved in at least one additional extracurricular activity or sport

3. Jill will report no suicidal ideation for 3 consecutive weeks

4. Jill will learn coping skills, including problem solving and emotional regulation. This will be measured by her demonstrating these skills during therapy sessions and bringing in homework assignments for two consecutive

Date Established 10-9-06 10-9-06 10-9-06 10-9-06

Projected Completion Date 10-9-06 11-02-06 12-02-06 1-16-07

Date Acheived 10-9-06 11-09-06 11-23-06 2-12-07

weeks that show she practiced them between sessions. 5. Jill will learn to identify maladaptive, negative thoughts

and how to replace them with more positive, adaptive thoughts. This will be measured by her demonstrating these skills during therapy sessions and bringing in homework assignments for two consecutive weeks that show she practiced them between sessions.

6. Jill will identify maladaptive, negative thoughts related to poor self-esteem and replace those with positive, adaptive thoughts. This will be measured by her demonstrating these skills during therapy sessions and bringing in homework assignments for two consecutive weeks that show she practiced between sessions.

7. Jill will identify three areas of interest and strength and become (or continue to be) involved in activities that utilize her strengths.

10-9-06 3-19-07 3-19-07

4-02-07 New projected date: 6-4-07 6-4-07 6-4-07

Responsible Person(s) 1. Tom Thumb, Ph.D.

Intervention/Action Individual therapy to help Jill learn and implement coping skills and to help her identify, process and resolve feelings and concerns.

2. Jill Spratt

3.

Responsible Person(s):

1. Tom Thumb, Ph.D.

Intervention/actions: Family Therapy to provide psycho-education about depression to increase parents’ insight into Jill, and to increase parents’ ability to support and encourage Jill to utilize new coping skills.

2. Jill Spratt

3. Jack and Joan Spratt, father and step-mother

Responsible Person(s): Jack Horner, M.D.

1.

Intervention/actions: Medication Management

2. 3.

Responsible Person(s): 1.

Intervention/actions:

2. 3.

Review Date: 3-19-7

Progress: A the beginning of treatment, family established a safety plan and followed it until Jill was free of suicidal ideation for three weeks. Jill participated in the extracurricular sport of basketball. Jill has demonstrated steps to problem solving, identifying and modulating emotions, and relaxation training in session. She brought in homework assignments demonstrating that she used problem solving and relaxation skills for two consecutive weeks. Beginning in December, 2006, she has brought her feelings journal homework to 10 out of 12 therapy sessions. Education has been provided on identifying and replacing negative, maladaptive thoughts but Jill cannot consistently demonstrate these skills in session yet. Her YSR Withdrawn/Depressed t score has dropped to 66.

Review Date:

Progress:

2. Problem/Symptom: Family Conflict currently is manifested by rude comments towards her step-mother and frequent arguing between Jill and her step-mother. “Rude” behavior towards her step-mother included eye rolling; walking away while her step-mother tried to talk to her; using a hostile or sarcastic tone of voice; and making

comments such as “you can’t tell me what to do, you’re not my parent.” Long Term Goal: Reduce family conflict and increase positive family interactions. This will be measured by reducing evasive/withdrawn interactions with her father to 1 time a week for 3 consecutive weeks; reducing arguing/rudeness towards her step-mother to 7 times a week for 3 consecutive weeks; and family will report at least one positive interaction/family activity per day for 3 consecutive weeks. Anticipated completion date: 6-4-07 Short Term Goals/Objectives:

1. Gather baseline data on evasive/withdrawn interactions with father and arguing/rudeness with step-mother.

2. Family will establish routine times in the week for communication and/or family activities (i.e., family meetings, family fun nights). This will be measured by the family establishing a schedule for communication/activities and reporting the number of times each week that they followed the schedule. 3. Jill and her father will learn communication and conflict resolution skills. This will be measured by Jill and her father demonstrating the skills, without coaching, to successfully discuss and resolve issues in 2 consecutive family therapy sessions. 4. Jill and her step-mother will learn communication and

conflict resolution skills. This will be measured by Jill and her step-mother demonstrating the skills, without coaching, to successfully discuss and resolve issues in 2 consecutive family therapy sessions.

5. Reduce evasive/withdrawn interactions with father to 3 times a week

6. Reduce arguing/rudeness to step-mother to 14 times a week

7. Reduce evasive/withdrawn interactions with father to 1 time a week.

8. Reduce arguing/rudeness to step-mother to 7 times a week.

Date Established 10-2-06 10-9-06 10-9-06 10-9-06 10-9-06 10-9-06 10-9-06 10-9-06

Projected Completion Date 10-9-06 10-23-06 11-23-06 12-23-06 New projected date: 6-4-07 1-23-07 2-23-07 3-9-07 4-6-07 New projected date: 6-4-07

Date Achieved 10-9-06 10-23-06 11-16-06 12-11-06 2-16-07 2-2-07

Responsible Person(s): .

1. Tom Thumb, Ph.D.

Intervention/actions: Family Therapy to explore and help family understand family dynamics, negative patterns and problems in family structure; and to help family learn and use communication and conflict resolution skills.

2. Jill Spratt

3. Jack and Joan Spratt, father and step- mother

Responsible Person(s):

1. Tom Thumb, Ph.D.

Intervention/actions: Individual Therapy to explore, process and resolve Jill’s feelings about family members, rules and structure; and to reinforce using good communication, conflict resolution and coping skills at home.

2.Jill Spratt 3.

Responsible Person(s): 1.

Intervention/actions:

2. 3.

Intervention/actions: Responsible Person(s): 1.

2. 3.

Review Date: 3-19-7

Progress: For the past four weeks, family has held 4/4 scheduled family meetings, 3/4 family movie nights, and Jill and her father have talked for at least 15 minutes a day 25/28 days. Jill and her father have demonstrated communication and conflict resolution skills in session. For the past four weeks, father reports Jill has had 2 evasive/withdrawn interactions with him. Jill and her step-mother have not successfully demonstrated use of conflict resolution skills in session. During the past four weeks, there have been 43 arguing/rude interactions between Jill and her step- mother.

Review Date:

Progress:

Involvement of Family: Father and step-mother will participate in family therapy and follow through on homework assignments to improve family functioning. Ms. Spratt recently made a commitment to participate more regularly in family therapy. Father and step-mother will formally (behavior counts and homework assignments) and informally monitor Jill’s symptoms, problems and progress. Father will support Jill in implementing new skills and becoming more active. Services Needed beyond scope of organization or program: Medication Management by Dr. Jack Horner Estimated Completion date for level of care: 6-4-07 Aftercare Plans: It is anticipated that Jill will not need ongoing outpatient psychotherapy at the time of discharge. She will continue to receive medication management with Dr. Jack Horner. Patient /Responsible Party Signature: Provider Signature: Tom Thumb, Ph.D. Must be a true signature, Rubber stamp signatures are not allowed Electronic signatures are acceptable

Date: 3-19-07

Provider Name/Title: (Print) Tom Thumb, Ph.D., Licensed Psychologist