MASTER TREATMENT PLAN I. Vital Information: Name: DOB: Age: Sex: Race: SS#: Medicaid#: Parents: Rights: Date of admission: LOC: Date of Report: On ________ the ____________ cottage treatment team met to review and update this treatment plan. I.Y. Issues requested to be addressed in this meeting: Kid: PD: Others: II. Progress to Date and Current Status a.) Resident's View (Subjective): b.) Staff View (Objective) - Course - Incidents - Restraints - Point Scores III. Additional History *IVa. Diagnoses (by Dr. Bates) *IVb. Current Medications V. Assessment and Interventions for Special Needs by Domain 528-2.a-f *a. Physical: Height: Weight: Next Physical:_______ Next Dental:_________ Physical Stage of Adolescence: Pre Early Early/Middle Middle Late Assessment: Strengths: Special Needs: Actions: *b. Familial: ... *c. Educational - IQ info - Grade Level - Academic testing levels (Reading, Math, Spelling) - Learning strengths or disabilities. - School history - Special Cottage Team interventions (if any): See Section VII. d. Educational. *d. Social/Behavioral *e. Psychological/Emotional f. Self-harm considerations (if applicable) g. Informational VI. Overview of Special Issues: *a. Assessment: *b. Goals for Treatment: *c. Discharge Plan: *- Current Permancy Plan: - Recommended: - Predicted: *d. Estimated Length of Stay: - Recommended - Predicted e. Prognosis: *VII. Detailed Plan to address Other Needs: i. Domains 0. Informational Need: Other than specified above, no additional information is required at this time. Plan: Additional information will be sought as required. a. Physical Needs & Goals 1. Continue to take all medications as prescribed 2. Learn and practice good hygiene 3. Eat healthy portions of a balanced diet Strategies & Staff Instructions The cottage counselors should provide this client with a healthy diet and the opportunity for daily physical exercise. Counselors should follow the normal routine for his medical and dental needs. The staff will assist this client in developing good hygiene practices and ensure that he has everything needed to care for himself. b. Family Section Familial Needs & Goals 1. Learn to respect authority in a family setting 2.Work through emotional issues regarding his experiences with his biological family 3.Learn to compromise and cooperate with others around him Strategies & Staff Instructions This client should be subjected to a family atmosphere with clear structure and rules. Positive role models in the cottage and individual therapy sessions with his therapists will help this client identify and address the areas in which he struggles. The client will have an opportunity at the cottage to learn his role in a family setting and develop coping skills to use when he is frustrated with his family. c. Educational/Vocational This client is being recommended for Charter school. He attends special education classes. 1School personnel will encourage an interest in school and assist this client in planning his educational future, Monitoring and assessment will be done by consulting professionals in order to ensure this client's success. He will also be presented with options for post-graduation plans and alternatives for continued education. Educational/Vocational Needs & Goals 1. Practice challenging himself to increase confidence in school. 2. Resist negative attention that pulls him off task in the classroom. 3. Take advantage of teachers assistance when presented with areas that he does not understand Strategies & Staff Instructions School personnel will encourage an interest in school and assist this client in planning his educational future, Monitoring and assessment will be done by consulting professionals in order to ensure this client's success. This client will also be presented with options for post-graduation plans and alternatives for continued education. d.) Social/Behavioral - Social Needs & Goals 1. Develop positive social skills. 2. learn to be tolerant of others 3. Develop ways to manage anger that are socially acceptable. Strategies & Staff Instructions This client needs to be included in all age-appropriate recreational groups and therapeutic activities. Consistent rules and respect for authority figures should be reinforced. Recreation 1. Increase motor skills/hand eye coordination 2. Build self-esteem/self confidence 3. Educational/increase knowledge 4. Increase communication skills 5. Outlet for displayed anger & aggression 6. Build trust in others/integrity 7. Specific Recreation Target Goal 8. Promote teamwork/cooperation/sharing 9. Positive peer interaction/social skills 10. Promote development of interpersonal skills 11 Promote physical fitness/maintain health 12. Relationship builder/allows bonding 13. Decrease anxiety/anxious feelings - Recreational / Leisure Needs & Goals 1. Show age appropriate behaviors. 2. Demonstrate respect for staff and peers. 3. Improve social interaction with peers. Recreational/Leisure Strategies & Staff Instructions this client needs to be included in all age-appropriate recreational groups and therapeutic activities. Consistent rules and respect for authority figures should be reinforced. this client will be encouraged to engage in group and individual activities and therapeutic games. Staff will monitor this client for delinquent behavior and allow him opportunities to participate in experiential trips when his behavior warrants. Spiritual/Moral Section - Spiritual/Moral Needs and Goals 1. Begin to recognize the spiritual aspects of life. 2. Understand the connection between spirituality and moral issues. 3. Begin to address the most basic spiritual issues. Spiritual / Moral Strategies and Staff Instructions Staff should be available to answer any questions that this client may have regarding spiritual matters or be able to direct him to someone that can. Staff should encourage this client to live a life that has high moral character. - Behavioral Section Staff will utilize behavior modification in the cottage along with consistent structure in order to assist this client in learning more positive behaviors and reactions. The PAPH certified physical restraint will be used if this client becomes a danger to himself or others. Identify and address depression, low self-esteem, verbal aggression, low frustration tolerance, and defiant attitude. Address as needed in counseling appropriate anger management skills and appropriate peer relations, as well as assisting him with learning advanced social skills. Behavioral Needs & Goals 1. Improve responses to authority figures. 2. Increase coping skills by communicating thoughts and feelings before they overwhelm him. 3. Utilize opportunities for time outs to think about his response before acting. Behavioral Strategies & Staff Instructions This client will require behavior modification, applied by the counselors, to reduce his maladaptive behaviors. Individual therapy sessions with on reality techniques and consequences. this client should be monitored for depression, low self-esteem, verbal aggression, low frustration tolerance, and defiant attitude, suicidal ideation, physical aggression, affect, property destruction, and anger outbursts. If this client is considered to be a danger to himself or others, a PAPH certified physical restraint will be necessary. Staff will model appropriate behavior for Brandon. The staff will take Brandon to all scheduled appointments. The staff will help Brandon use his coping skills to help him reach the goals that he help set for himself during the Treatment team review. The staff will encourage Brandon to want to work on his goals and help him understand the purpose of setting and achieving goals. e.) Emotional/Psychological This client will be seen on an individual basis with ______ frequency by his therapist, _______,, because of his LOC being _________. He will also participate in the Azleway substance abuse program(ASAP) if indicated. Staff will provide a structured, supportive environment which will allow time to deal with his problems in a safe, healthy manner. Justin will utilize the coping skills he came up with during the treatment team meeting. Emotional / Psychological Needs & Goals 1. Provide a consistent daily structure to allow this client to gain greater success meeting his daily goals 2. Develop positive pro social skills. 3. Increase communication skills to help this client reduce anger and anxiety. Strategies & Staff Instructions This client will receive counseling regarding the problems related to his biological family, his maladaptive behaviors and his emotions. This client should be included in cottage group therapy, conducted by his therapist and counselors, as well as, individual therapy dealing with his other problems. Positive role models and consistent authority in the cottage and school will help this client develop trust and facilitate his bonding with others. He should be monitored by all staff for any depression, low self-esteem, verbal aggression, low frustration tolerance, and defiant attitude, suicidal ideation, physical aggression, flat affect, property destruction, and anger outbursts. ii. Other Goals for Treatment Short Range: The staff will assist this client in adjusting to cottage life and will formulate a treatment plan describing the child's initial needs and the plan of action that will be utilized in order to care for the child. This client will also engage in counseling, and will undergo an assessment by consulting professionals. Staff will encourage involvement in recreational activities, and will evaluate the child's behavior for the continued necessity of psychotropic medication. Contact will be made with TDFPS, and an ARD assessment will be needed to determine placement in school. The school administrator will also acquire the child's last IEP to assist with educational assessment and placement in the appropriate classes. this client will be offered the chance to become stable in the RTC placement so that he can begin to make plans for a transition to moving toward and appropriate permancy plan. Long Range: This Client will be encouraged and assisted in completing the prescribed goals in school. Staff will provide a structured, supportive environment which will allow his intellectual abilities to flourish, allowing time for him to learn new skills so This Client will have an opportunity to deal with his problems in a safe, healthy manner. This Client will also be encouraged to address, in therapy, the breakdown of his biological home, as well as, his issues with his biological parents. Staff will also assist the child in addressing, in therapy, any issues with poor coping skills, problems with authority, impulse control issues, assaultive behaviors, and anger outbursts including any history of physical aggression, fighting, defiant behavior, suicidal ideations, and lack of insight. Upon successful completion of the RtC program, arrangements will be made to effect the appropriate discharge plan. VIII. Summary a.) Goals of Special Interest b.) Coping-Skills