Maine.gov
Psychiatric Medication Support PlanClient: Dob: Click here to enter text.Initial Plan Date: Click here to enter text.Last Updated: Prescribing Physician: Click here to enter text.Psychiatric Medication (including dose and frequency): Click here to enter text.Target Symptoms: Click here to enter text.Diagnosis: Click here to enter text.If PRN, criteria for use: Click here to enter text.Behavioral Criteria to determine benefit: Click here to enter text.Side effects/Adverse Reactions that must be reported to prescribing physician: Click here to enter text.Potential Long Term effects: Click here to enter text.Other supports to help alleviate symptoms: Click here to enter text.Plan for review and monitoring of medication effectiveness & side effects: ................
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