Child/adolescent Psychiatric Service Form Page 4
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4*Treatment plan (include behavior plan, parenting work, family interventions): _____________________________
__________________________________________________________________________________________
*Specific to behavior plan, what assistance will family/guardians need in order to maintain behavior plan? _______
__________________________________________________________________________________________
*Medications: _______________________________________________________________________________
__________________________________________________________________________________________
*Medication Adherence? Barriers to adherence? ___________________________________________________
__________________________________________________________________________________________
*If this is a concurrent review, what progress has been made in reducing inappropriate behaviors? _____________
__________________________________________________________________________________________
*If this is a concurrent review and no progress has been made in reducing inappropriate behaviors, how will the
treatment plan be changed? ___________________________________________________________________
__________________________________________________________________________________________
*Discharge readiness behavior (What specific behavior(s) will indicate readiness to discharge)? _______________
__________________________________________________________________________________________
*Discharge plan: ____________________________________________________________________________
__________________________________________________________________________________________
*PCP involvement and efforts to coordinate care: __________________________________________________
__________________________________________________________________________________________
*Other information: _________________________________________________________________________
__________________________________________________________________________________________
*Estimated length of stay or duration of service: ____________________________________________________
__________________________________________________________________________________________
*Estimated discharge date: _____________________________________________________________________
__________________________________________________________________________________________
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or
your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby
notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received
this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via
the U.S. Postal Service. Thank You.
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