Client & Service Details

Client Legal Name *

MRN

DOB

Medicaid / ID

Plan Start Date *

Target Review Date (90 days)

Diagnostic & Service Summary

Primary Diagnosis (DSM-5-TR)

ICD-10

Secondary Diagnosis

ICD-10

Medical Necessity Justification

Recommended Service

Frequency & Intensity

SNAP Summary

Strengths, Needs, Abilities, Preferences, & Natural Supports

Treatment Goals & Objectives

Risk & Safety Summary

Summary of Risk & Safety Considerations

Care Coordination

Coordination Plan

Signatures

We have participated in the development of this plan and agree to its provisions. We understand our right to appeal.

Clinician / QMHP Name/Credentials *

Clinician / QMHP Signature *

Date *

Client Name

Client Signature

Date

Guardian Name (if applicable)

Guardian Signature

Date

LMHP Supervisor Name/Credentials (Review) *

LMHP Supervisor Signature *

Date *

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Comprehensive Treatment Plan