Outpatient Mental Health Treatment Plan Example

Content: Outpatient Mental Health Treatment Plan Please complete this entire form and fax to the attention of Administrative Assistant, Behavioral Health, Clinic Phone: Address: Patient Name: City: Subscriber ID: State: Zip: Fax No.: Patient DOB: First date of service: Current Psychiatric Status (mark where applicable): Symptoms/Problems Depressed mood Obsessions/compulsions Anxiety Impulsiveness Somatic complaints Poor judgment Sexual issues Impaired concentration Appetite disturbance Irritability Hyperactivity Sleep disturbance Delusions Paranoia Panic attacks Hallucinations Phobias Impaired memory Alcohol abuse Opiate abuse Prescription medicine abuse Polysubstance abuse Initial date: Mild Moderate Severe Current date: Mild Moderate Severe  Over ¼ Current Psychiatric Status—Risk Assessment (mark where applicable): Initial date: Mild Moderate Suicidality Homicidality Violence Severe Current date: Mild Moderate  Severe Thought Plan Means Method Gesture  Current Medications (Please list name, dose, date started, and compliance.): Current medications are prescribed by:  Psychiatrist Primary care provider Other: Narrative Summary (Please note current level of functioning in life domains,