PNMI 101 Sample Packet, Summaries of Acting

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Making a Difference for Children, Families and Communities

PNMI 101

Sample Packet

Making a Difference for Children, Families and Communities

Sample Treatment Plan Signature Pages

Licensed Practitioner Authorization (Approval): I have assessed this child/youth and reviewed all available information regarding this child/youth's needs and

progress, and by my signature below I am authorizing this plan as necessary and appropriate. Agency-Authorized Licensed Clinical Practitioner Approving This Plan:

Elizabeth Director, LCSW, Group Home Director Elizabeth Director, LCSW 5/31/ 15

Printed Name, Credentials, Agency Title signature (Or E-Signature), Credentials Date

Team Members (Persons who participated in the development of this plan):

Clinician I have discussed this plan with youth to ensure his/her complete understanding and have attempted to incorporate his/her concerns and suggestions into this plan.

- Yes - No (Explanation):________________________________________________________ I have discussed this plan with the child's parents to ensure their complete understanding, and have attempted to incorporate their concerns and suggestions into this plan: - Yes - No (Explanation):______________________________________________________ Clinician Signature: Mary Therapist, LCSW **_** Mary Therapist, LCSW 05/31/ 15 printed Name/Credential signature and credentials date Child/Youth : I participated in the development of this plan through: Attendance at planning meeting - Participation in a planning meeting via phone Discussion with a clinician- Other- ___ I did not participate but have reviewed this plan- Child/Youth Signature: JP O 'Example/Youth JP O' Example 05/31/ 15 printed name/relationship signature date Explanation for child/youth not participating in the development of this plan and/or not signing it: ____________________________________________________ DCF: I participated in the development of this plan through: Attendance at planning meeting - Participation in a planning meeting via phone Discussion with a clinician- Other- ___ I did not participate but have reviewed this plan- DCF Signature: John Doe/AOSW John Doe 05/31/ p rinted name/title signature date Explanation for DCF staff not participating in the development of this plan or indicating they do not accept this plan and/or not signing it: _______________________________________

Making a Difference for Children, Families and Communities

Sample Treatment Plan Client: Johnny O'Brian Goals , Objectives, Interventions and Strengths to Address Specific Vulnerabilities/Needs: Vulnerability/Symptom/Need/Impairment in Daily Living 1: Chronic depressed mood, conflicts with peers, chronic irritability and frequent anger explosions. Strengths that Support Positive Outcomes Described as able to listen to advice, estimated to be slightly above average intelligence, reported as insightful. Source: (Diagnosis/Evaluation/Assessment Utilized as Source) Dr. Pill's Psychiatric Evaluation 1/16/ Goal 1: ( Anticipated Outcome) Johnny will regularly exhibit a positive mood, a calm affect and a pro-social attitude. Progress: Johnny has made good progress on this goal AEB by obtaining and maintain green level. Objectives (incorporate strengths as appropriate): Service Type: Service Description: Session Duration Frequency Staff Responsible: Progress: 1A: Johnny will develop positive coping skills and social skills to help develop and maintain healthy relationships with adults and peers. Progress will be measured by regular positive reports from his therapist. Individual Therapy Provide cognitive behavioral therapy to assist with identifying patterns of thoughts, beliefs and actions relating to frequent anger outbursts and depressed mood

Minutes 1x/week Clinician- Therapist/ Mary Nice, LCSW Moderate-Johnny has worked with therapist on new interpersonal strategies. He is now better able to replace negative self- judgement and negative thinking with healthier, positive approaches. He still needs to continue to work on it and on elevating his self-esteem 1B: Johnny with improve symptoms of depression by taking his medication as prescribed and meeting with the psychiatrist as scheduled. Medication Management Provide regular consultation regarding effectiveness of medication

Minutes 2x/month Child Psychiatrist/ Robert Pill, MD Good. Johnny attended all his medication management sessions with the psychiatrist, takes his medications regularly. The meds have consistently had a positive effect in his mood amelioration and stabilization and his affect is positive most of the times.

Making a Difference for Children, Families and Communities

1C: Johnny will learn and use healthy ways of controlling his anger. Progress will be measured by regular reports from milieu staff and youth. Proactive Milieu Service

• Identify Triggers
• Identify/practice Coping Skills
• Identify ways to reduce stress
• Identify physiological stress symptoms
• Practice asking to utilize coping skills
• Identify barriers
• Identify supports

Minutes Daily Milieu Coach Moderate. Johnny only had a few anger outburst and currently he is better to maintain awareness of what others say about him and to him and how he reacts to it. He needs to continue to work on self- awareness and triggers identification. 1D: Johnny will learn and use positive ways of engaging in healthy social interactions with peers and adults. Progress will be measured by regular reports from milieu staff and youth. Proactive Milieu Service

• Practice having a conversation
• Ask for help
• Look in a person’s eyes when talking
• Reading body language
• Taking turns talking
• Cultural differences

Minutes Daily Milieu Coach Moderate - Staff reported Johnny having had less instances of arguing with peers and acting in opposition of staff. He was observed seeking to engage in conversation with peers and staff more often this period than the last plan’s period. He also argued less often with peers while engaged in activities with them. He needs to continue to work on it especially the area of trigger identification and listening to others for positive reactions. Discharge Planning Discharge Plan: Reunification Projected Caregiver: Father Projected Discharge Date: 10/1/ Services required after discharge: Medication management, individual therapy, family therapy Barriers to reunification: none identified at this time Concurrent planning: n/a

Making a Difference for Children, Families and Communities

Treatment Plan Timeliness Tool

Making a Difference for Children, Families and Communities

MTPPR Tracking Tool

Making a Difference for Children, Families and Communities

Example MTPPR Progress Statement (Standard 34) _Remember to begin documentation of progress in the Symptomatology Box & continue documentation in the Recovery & Resiliency Box. There is no need to write out all Goals & Objectives if they can be linked to the treatment plan. They can be identified in the progress narrative by G1, G 1 O 1 , G1O2, G2,_

G 2 O 1 , G2O2, G2O3 etc.

Example:

G1: Jack has demonstrated growth in maintaining a positive emotional state, evidenced by increased peer interactions, a decrease in oppositional behaviors &

improved medication compliance. He has maintained safe behaviors as there have been no AWOL’s, protective holds or police interventions during this review

period. G 1 O 1 : Jack has willingly participated in all group sessions. He requires re-direction at times due to inappropriate social communication, however, more

recently has been able to maintain composure in group. G 1 O 2 : Jack continues to require frequent prompts in order to engage in appropriate peer interactions; at

times he requires intervention from staff to assist him in managing his behaviors. G2 : Jack has continued to complete his hygiene 2x/day, without prompts from staff.

He has been more engaged with staff & peers & participating in all daily activities. In contrast, this has led to the opportunity for staff to observe on-going

inappropriate social interactions, resulting in an increase in teaching opportunities for staff & Jack to practice positive prosocial skills during group, individual therapy

and within the milieu. Jack continues to struggle with unplanned changes in routine, time management and limit setting, specifically with use of his electronics. G2O 1 :

Jack consistently takes his medications without issue. G2O 2 : Jack has continued to demonstrate an increase in his ability to communicate his needs with completing

life skills/ADL tasks, to include being more receptive to household rules/expectations, particularly around household chores. G2O 3 : Jack has been able to complete

hygiene without prompting and with minimal support from staff.