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Page: FORMTEXT ????? of FORMTEXT ?????Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Date of Admission: FORMTEXT ?????Organization/Program Name: FORMTEXT ?????DOB: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Transgender FORMCHECKBOX Annual IAP-Date: FORMTEXT ????? FORMCHECKBOX Revised IAP-Date: FORMTEXT ?????Person’s Strengths, Preferences and Skills and How They Will be Used to Meet This Goal: FORMTEXT ?????Supports and Resources Needed to Meet This Goal: FORMTEXT ?????Potential Barriers to Meeting This Goal: FORMTEXT ?????Person Served Will: FORMTEXT ?????Parent/Guardian/Community/Other Will: ( FORMCHECKBOX Not Clinically Indicated) FORMTEXT ?????Goal #: FORMTEXT ?????Linked to Assessed Need(s): FORMTEXT ????? from form dated FORMTEXT ?????: FORMCHECKBOX CA FORMCHECKBOX CA Update FORMCHECKBOX Psych Eval. FORMCHECKBOX Other: FORMTEXT ?????Start Date: FORMTEXT ?????Target Completion Date: FORMTEXT ?????Desired Outcomes for this Assessed Need in Person’s Words: FORMTEXT ?????GOAL(State Goal Below in Collaboration with the Person Served/Reframe Desired Outcomes): FORMTEXT ?????Objective # FORMTEXT ?????: FORMTEXT ?????Intervention(s) / Method(s)Start Date: FORMTEXT ?????Target Completion Date: FORMTEXT ?????1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????Service Modality: FORMCHECKBOX Individual Therapy FORMCHECKBOX Couple/ Family Therapy FORMCHECKBOX Medication Services FORMCHECKBOX Case ManagementFrequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Modality: FORMCHECKBOX Group FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Frequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Page: FORMTEXT ????? of FORMTEXT ?????Person’s Name (First / MI / Last): FORMTEXT ?????Record#: FORMTEXT ?????Goal #: FORMTEXT ?????Objective # FORMTEXT ?????: FORMTEXT ?????Intervention(s) / Method(s)Start Date: FORMTEXT ?????Target Completion Date: FORMTEXT ?????1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????Service Modality: FORMCHECKBOX Individual Therapy FORMCHECKBOX Couple/ Family Therapy FORMCHECKBOX Medication Services FORMCHECKBOX Case ManagementFrequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Modality: FORMCHECKBOX Group FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Frequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Objective # FORMTEXT ?????: FORMTEXT ?????Intervention(s) / Method(s)Start Date: FORMTEXT ?????Target Completion Date: FORMTEXT ?????1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????Service Modality: FORMCHECKBOX Individual Therapy FORMCHECKBOX Couple/ Family Therapy FORMCHECKBOX Medication Services FORMCHECKBOX Case ManagementFrequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Modality: FORMCHECKBOX Gro FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Frequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Objective # FORMTEXT ?????: FORMTEXT ?????Intervention(s) / Method(s)Start Date: FORMTEXT ?????Target Completion Date: FORMTEXT ?????1. FORMTEXT ????? 2. FORMTEXT ?????3. FORMTEXT ?????Service Modality: FORMCHECKBOX Individual Therapy FORMCHECKBOX Couple/ Family Therapy FORMCHECKBOX Medication Services FORMCHECKBOX Case ManagementFrequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Modality: FORMCHECKBOX Group FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Frequency: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Type of Provider FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Page: FORMTEXT ????? of FORMTEXT ?????Person’s Name (First / MI / Last): FORMTEXT ?????Record#: FORMTEXT ?????This Section Mandatory for Outpatient Substance Abuse Counseling Only (Check Here if Not Applicable: FORMCHECKBOX )Medications as Reported by Person Served on Date of IAP Development (None Reported: FORMCHECKBOX )Medication NameDosePlans for Change-Including Rate of DetoxPrescribed By FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Does the person served have a disability that requires modification of policies, practices, or procedures? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, document any modifications made: FORMTEXT ?????Describe the plan for initiation, coordination, and management of concurrent additional substance use disorder treatment, treatment of co-occurring disorders, and/or primary medical care: FORMTEXT ????? Other Agencies/Community Supports and Resources Supporting Individualized Action Plan: FORMCHECKBOX None Reported ( FORMCHECKBOX No Change)Agency NameContact and TitleServices Currently ProvidedRelease Signed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoTransition/Level of Care Change/Aftercare/Discharge Plan ( FORMCHECKBOX No Change)Anticipated Date: FORMTEXT ?????Criteria-How will the provider/individual/parent guardian know that level of care change is warranted?(Check All that Apply) FORMCHECKBOX Reduction in symptoms as evidenced by: FORMTEXT ????? FORMCHECKBOX Attainment of higher level of functioning as evidenced by: FORMTEXT ????? FORMCHECKBOX Treatment is no longer medically necessary as evidenced by: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Plan Completed by (Name, Title, Program): FORMTEXT ?????Was the person served provided copy of the IAP? FORMCHECKBOX Yes FORMCHECKBOX No, Reason: FORMTEXT ?????Person’s Signature (Optional, if clinically appropriate) FORMTEXT ?????Date: FORMTEXT ?????Parent/Guardian Signature (If appropriate): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor Signature (if needed): FORMTEXT ?????Date: FORMTEXT ?????Psychiatrist/MD/DO (If required): FORMTEXT ?????Date: FORMTEXT ?????Next Appointment:Date: FORMTEXT ????? - FORMTEXT ????? Time: FORMCHECKBOX am FORMCHECKBOX pm ................
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