Support Plan
Client Name:
[ {{ client.client_id }} ] {{ client.fname}} {{ client.lname}}
Start Date:
End Date:
Select Unit:
{{ place_str }}
{% for unit in units %}
{{unit.unit_id}} -- {{ unit.unit_lname }}
{% endfor %}
Treatment Team:
Case Manager:
Backup:
Supervisor:
Chart Number:
Admission Criteria:
Client is 18 years or older, has DSM5 diagnosis:
Yes
No
Client demonstrates marked difficulties in self care:
Yes
No
Client shows marked difficulties in maintaining social functioning:
Yes
No
Client exhibits reliance on psychiatric treatment and support:
Yes
No
Client exhibits marked restriction of ADL:
Yes
No
Client exibits deficiencies of concentration and task completion:
Yes
No
Additional Information:
Rights and Grievance Procedures Reviewed With Client:
Yes
No
Date:
Functional Assessment:
{% for funct in funct %}
Skill Area: {{funct.skill_area}}
Assessment: {{ funct.skill_level }}
{% endfor %}
Treatment Goals:
Goal 1 - Functional Assessment Skill Area:
{% for skill in skill %}
{{ skill.skill_area[:60] }}{% if skill.skillarea|length > 60 %}...{% endif %}
{% endfor %}
Status:
2 - Active
1 - Attained
3 - Discontinued
Level:
Needs Attention
Needs Immediate Attention
Adequate
Excellent
Goal 1 - Client will:
Goal 1 - Staff will:
Goal 1 - Evaluation:
This is a new goal.
Goal 2 - Functional Assessment Skill Area:
{% for skill in skill %}
{{ skill.skill_area }}
{% endfor %}
Status:
2 - Active
1 - Attained
3 - Discontinued
Level:
Needs Attention
Needs Immediate Attention
Adequate
Excellent
Goal 2 - Client will:
Goal 2 - Staff will:
Goal 2 - Evaluation:
Goal 3 - Functional Assessment Skill Area:
{% for skill in skill %}
{{ skill.skill_area }}
{% endfor %}
Status:
2 - Active
1 - Attained
3 - Discontinued
Level:
Needs Attention
Needs Immediate Attention
Adequate
Excellent
Goal 3 - Client will:
Goal 3 - Staff will:
Goal 3 - Evaluation:
Goal 4 - Functional Assessment Skill Area:
{% for skill in skill %}
{{ skill.skill_area }}
{% endfor %}
Status:
2 - Active
1 - Attained
3 - Discontinued
Level:
Needs Attention
Needs Immediate Attention
Adequate
Excellent
Goal 4 - Client will:
Goal 4 - Staff will:
Goal 4 - Evaluation:
Submit
{% include '_footer.html' %}
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