Behavioral Consultation and Primary Care



XXXXXXX, Behavioral Health Consultant

XXXX Health Center, XXXXXX PHONE: XXX-XXX-XXXX

[pic]

[pic] [pic] [pic]

Plan:

XXXXXXX, Behavioral Health Consultant

XXXX Health Center, XXXXXX PHONE: XXX-XXX-XXXX

[pic]

[pic] [pic] [pic]

Plan:

XXXXXXX, Behavioral Health Consultant

XXXX Health Center, XXXXXX PHONE: XXX-XXX-XXXX

[pic]

|PLAN: |Week 1 |

| |Sun |Mon |Tues |Wed |Thur |Fri |Sat |

|1. | | | | | | | |

| |Week 2 |

|2. |Sun |Mon |Tues |Wed |Thur |Fri |Sat |

| | | | | | | | |

Your notes about behavior change experiment:

PLEASE RETURN: _________________ FOR VISIT WITH _______________________

XXXXXXX, Behavioral Health Consultant

XXXX Health Center, XXXXXX PHONE: XXX-XXX-XXXX

[pic]

|PLAN: |Week 1 |

| |Sun |Mon |Tues |Wed |Thur |Fri |Sat |

|1. | | | | | | | |

|PLAN: |Week 2 |

| |Sun |Mon |Tues |Wed |Thur |Fri |Sat |

|2. | | | | | | | |

Your notes about behavior change experiment:

PLEASE RETURN: __________________ FOR VISIT WITH _______________________

XXXXXXX, Primary Care Behavioral Health Consultant

XXXX Health Center, XXXXXX PHONE: XXX-XXX-XXXX

|My SMART Goal |

|Specific: | |

|Where will you do it? | |

|With whom will you do it? | |

|How often will you do it? | |

|Measureable: | |

|How much? | |

|How many? | |

|Attainable: | |

|What is most important to you? | |

|What do you hope to accomplish? | |

|Realistic: | |

|Are you able to do it? | |

|What can you do right now? | |

|How easy will this be to maintain? | |

|Timely: | |

|When do you want to accomplish this? | |

|Do you have a deadline? | |

PLEASE RETURN: _________________________ FOR VISIT WITH _______________________________

XXXXXXX, Primary Care Behaviorist

XXXX Health Center, XXXXXX PHONE: XXX-XXX-XXXX

|My SMART Goal |

|Specific: | |

|Where will you do it? | |

|With whom will you do it? | |

|How often will you do it? | |

|Measureable: | |

|How much? | |

|How many? | |

|Attainable: | |

|What is most important to you? | |

|What do you hope to accomplish? | |

|Realistic: | |

|Are you able to do it? | |

|What can you do right now? | |

|How easy will this be to maintain? | |

|Timely: | |

|When do you want to accomplish this? | |

|Do you have a deadline? | |

PLEASE RETURN: _____________________ FOR VISIT WITH ____________________________

|Resource |Phone Number |Resource |Phone Number |

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|Resource |Phone Number |Resource |Phone Number |

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Note: Make a table with the names and phone numbers of the community resources used most often; fit it to a half-sheet and photocopy it onto the back on your RX pad.

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Health

Relationships

Work, Play,

Spirituality

Health

Relationships

Work, Play,

Spirituality

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