Initial Treatment Plan Mental Health

IDAHO CRIME VICTIMS COMPENSATION PROGRAM Initial Treatment Plan CV#: Parent/Guardian: Therapist's Name: License #: Name of Supervising Therapist (if applicable): Name of Treatment Facility: Are you a provider under these programs?: Medicaid Medicare Blue Cross Indian Health Services Do you bill on a sliding fee scale? Yes Client's Name: Tax I.D. #: Credentials: TriCare Blue Shield No Other Rate billed for this client? Number of sessions to date: Indicate what sources of payment are available to the client: Date treatment began: 1. Please describe the presenting symptoms or conditions for which the client is seeking treatment. 2. Does the client have a history of previous mental health treatment? Yes No If so, please indicate approximate dates of treatment, reason for the treatment, duration of the treatment and, the results of the treatment. 3. Was there prior victimization or psychological trauma? Yes No If so, please describe. 4. Please provide a brief description of the crime as related to you, including the source of the information (i.e. client, parent or other). 5. Please describe any pre-existing conditions that may affect treatment, including any recent psychological stressors, and to what extent these conditions may have been exacerbated by the crime. C:\formdocuments\Initial Treatment Plan - Counseling (1/05) American LegalNet, Inc. www.FormsWorkFlow.com 6. Indicate percentage of treatment resulting from pre-existing or non-crime related conditions. 7. Describe the symptoms/conditions you are treating that are a direct result of the crime. % 8. Indicate percentage of treatment resulting from crime-related conditions. (Percentages from #6 and #8 should equal 100%) 9. Describe the client's support system and how it will be involved in the treatment. % 10. DSM IV Diagnosis (indicate the code and the descriptor). Axis I: Axis II: Axis III: Axis IV: Axis V: 11. Estimated duration of treatment: 12. Estimated cumulative cost of treatment: from $ to 13. List below the treatment goals for this client, give specific behavioral measures and projected dates to achieve these goals. Symptom/Condition Treatment Goal Method Target Date 14. I certify that the information provided in this treatment plan is true and accurate. I acknowledge that if the alleged offender is convicted, the Program will request the criminal court to order the alleged offender to pay restitution to reimburse the Program for expenses paid on behalf of the victim. I further acknowledge that this document may be submitted as evidence and that I may be called to testify regarding the mental health treatment outlined in this plan. Signature of Therapist Supervisor's Signature (if applicable) C:\formdocuments\Initial Treatment Plan - Counseling (1/05) American LegalNet, Inc. www.FormsWorkFlow.com Date Date