Free ForwardHealth Model Multi - Agency Treatment Plan, F11106 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11106 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

MODEL MULTI ­ AGENCY TREATMENT PLAN
Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the service. Name -- Member Birth Date -- Member Member Identification Number Date of This Plan Plan Review Date Case Manager List family members involved in treatment. 1. 2. 3. 4. 5. 6. List agency team members developing and implementing this plan (include title indicating discipline). 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Was parent or primary caregiver present? Yes No

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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Problem Summary: In the space provided below, describe the problems of the child and the family. Specify the elements of the problem that are to be addressed in treatment.

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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Mental Health Agency Response

Short Term Goal (Measurable)

Long Term Goal (Measurable)

Plan (Include the frequency of the intervention and the team member(s) responsible.)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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Social Services Agency Response

Short-Term Goal (Measurable)

Long-Term Goal (Measurable)

Plan (Include the frequency of the intervention and the team member(s) responsible.)

Measurable Results of the Intervention at the Time of Plan Review.

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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School Agency Response

Short-Term Goal (Measurable)

Long-Term Goal (Measurable)

Plan (Include the frequency of the intervention and the team member(s) responsible.)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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Juvenile Justice Agency Response

Short-Term Goal (Measurable)

Long-Term Goal (Measurable)

Plan (Include the frequency of the intervention and the team member(s) responsible.)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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Health Agency Response

Short Term Goal (Measurable)

Long Term Goal (Measurable)

Plan (Include the frequency of the intervention and the team member(s) responsible.)

Measurable Results of the Intervention at the Time of Plan Review

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MODEL MULTI-AGENCY TREATMENT PLAN F-11106 (10/08)

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Services Recommended by the Treatment Plan 1. 2. 3. 4. 5. 6.

Program Discharge Criteria

SIGNATURE -- Certified Psychotherapist / Substance Abuse Counselor SIGNATURE -- Psychologist / Psychiatrist*

Date Signed Date Signed

I (we) have read the foregoing treatment plan and give my (our) consent for my (our) child to receive the treatment outlined above. I (we) will agree to participate in the treatment intervention outlined above. SIGNATURE -- Parent(s) or Primary Caregiver * Either the in-home or multi-agency plan must be signed by a psychologist or psychiatrist. Date Signed

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