Treatment Plan

Consumer Name:

APS/CID#:

Individual Resilience/Recovery Plan (IRRP) All services requested on this page must accompany a therapeutic objective/intervention.

Start Date:

Service Type: (check one)

Problem List: Therapeutic Needs 1.

IFI

Core Services

Status A = Active M = Maintenance CR = Consumer Refused R = Referred D = Deferred S = Resolved

2. 3. 4. Transition/Discharge Plan Projected Date of Transition/Discharge

Plan for Transition/Discharge: (see detailed plan in chart)

Anticipated Step Down Service(s) What Hopes Did The Consumer Express In Regards To Their Recovery? (In Consumer’s Words)

Achievable Therapeutic Goals Need/Problem #1 Goal# 1

Target Date

Objective 1:

Target Date

Service Code

Intervention

1 .

Frequency Interval

Intervention

Service Code

2

Frequency Frequency Interval Target Date

Objective 2:

Service Code

Intervention

1

Frequency Frequency Interval

Intervention

Service Code

2

BH3601-Treatment Plan

Frequency

Frequency Frequency Interval

Jireh Counseling & Consulting Service, Inc.

Rev Mar 2008

Consumer Name:

APS/CID#:

Individual Resilience/Recovery Plan (IRRP) Need/Problem #2 Goal #2

Target Date

Objective: 1

Target Date

Service Code

Intervention

Frequency

1

Frequency Interval

Intervention

Frequency

2

Frequency Interval Target Date

Objective: 2

, 2008 Service Code

Intervention

1

Frequency Frequency Interval

Intervention

Service Code

2

Frequency Frequency Interval

Achievable Therapeutic Goals Need/Problem #3 Goal #3

Target Date

Objective: 1

Target Date

Service Code

Intervention

1

Frequency Frequency Interval

Service Code

Intervention

Frequency

2 Frequency Interval Target Date

Objective: 2

Service Code

Intervention

1.

BH3601-Treatment Plan

Frequency Frequency Interval

Jireh Counseling & Consulting Service, Inc.

Rev Mar 2008

Consumer Name:

APS/CID#:

Individual Resilience/Recovery Plan (IRRP) Intervention

Service Code

2.

Frequency Frequency Interval

Need/Problem #4 Goal #4

Target Date

Objective: 1

Target Date

N

Service Code

Intervention

1

Frequency Frequency Interval

Intervention

Service Code

2

Frequency Frequency Interval Target Date

Objective: 2

Service Code

Intervention

1

Frequency Frequency Interval

Intervention

Service Code

2

Frequency Frequency Interval

Signatures (Sign Legibly): My/our signature here indicates that I/we were actively involved in the treatment planning process, understand it, and accept responsibility to carry out my/our portion of the plan.

______________________________________________ JCCS Staff/Title Date

________________________________

______________________________________________ JCCS Staff/Title Date

________________________________________ Consumer Date

______________________________________________ JCCS Staff/Title Date

________________________________________ Other Significant Party Date

BH3601-Treatment Plan

Parent/Guardian

Jireh Counseling & Consulting Service, Inc.

Date

Rev Mar 2008

Consumer Name:

APS/CID#:

Individual Resilience/Recovery Plan (IRRP)

BH3601-Treatment Plan

Jireh Counseling & Consulting Service, Inc.

Rev Mar 2008