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Individual Treatment Plan Label
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Admission Date:
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Current Date
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Next Review Date (within 6 months)
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Current Phase of Treatment
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Primary Diagnoses:
• • •
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Primary Diagnosis Additional Comment
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Patient Assessment
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Patient Strengths:
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Patient Barriers:
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Other Factors:
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Does the patient have access to a PCP and Med Care?
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Does the patient have access to family planning services?
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What is the highest level of education?
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Is the patient currently employed?
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Patient's Job
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Does the patient have transportation?
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Type of transportation.
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Does the patient have a bank account?
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Does the patient and his family have adequate access to food?
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Currently living environment?
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Goals Header
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Goal # 1
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Interventions:
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Referral:
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Progress / Regress
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Goal # 2
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Interventions:
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Referral:
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Progress / Regress
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Goal # 3
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Interventions:
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Referral:
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Progress / Regress
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Goal # 4
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Interventions:
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Referral:
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Progress / Regress
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Goal # 5
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Interventions:
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Referral:
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Progress / Regress
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Is the patient attending 12 step groups?
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Frequency of attending AA / NA / CR?
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Does patient have family / friends who help obtain goals?
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Readiness to change from 1 to 10
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Patient agrees with goals and plan.
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What is patient's vision for recovery and milestones?
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Does patient understand that tapering is an option?
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Patient ready for taper?
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Initial treatment plan?
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