LHFS IIC Treatment Plan
Client Name:
Client CYBER ID#
Care Manager:
Referring Agency:
Axis I
Axis II
Axis III
Axis IV
Axis V
Client Strengths (Identify a minimum of three):
ISP Goals Indicated for In Home Services (Use Care Manager ISP):
Long Term Goals- no more than three- State the Long Term Goal, related to the presenting needs,
problems, and symptoms in finite, measurable, and observable terms; include 90 day date review date
Goal 1
Goal 2
Goal 3
Short Term Goals- at least one related to each long term goal- State the Short Term goals, related to the
presenting needs, problems, symptoms, measurable and observable terms; Be specific with
interventions used
Goal 1:
Responsible Person:
Frequency: Weekly
Target Date:
Goal 2:
Responsible Person:
Frequency: Weekly
Target Date:
Goal 3:
Responsible Person:
Frequency: Weekly
Target Date:
Discharge Plan or Transition Plan:
Review of Treatment Plan Review Date_________________
Discuss Progress on Short Term Goals Plan (leave blank on initial plans; update every 90 days):
Signatures- Must be original signatures
Individual (Client 14 or older must sign) ____________________________________Date_______
Parent or Guardian ________________________________________ Date_______________
Licensed Clinician__________________________________________ Date________________
Post completed plan in CYBER, and turn in original with signatures to LHFS with paperwork. Plans must
be completed 14 days from initial visit with family and entered into CYBER.