Ultimate Care Behavioral Health Services

3 Month Treatment Plan

(This review helps us keep your care up to date. Every 3 months you'll complete any needed assessments and review your treatment goals together with your care team.)

Date

Intake Month and Year

Patient Information

First Name

Middle Initial

Last Name

Date of Birth

What problems are you in treatment for?

Primary problem

Secondary problem

Please describe the primary problem

Please describe the secondary problem

Have you had thoughts or behaviors to harm yourself or someone else in the past month?

YesNo

Have you been hospitalized for your mental health within the last 3 months?

YesNo

Name of Hospital

Have your medications changed in the last 3 months?

YesNo

List any new or changed medications below.

Do you have access to firearms?

YesNo

Is the firearm in a lockbox?

YesNo

Complete an updated assessment and treatment plan

Because you've reached a 3 month interval from your intake date, completing the assessment and treatment plan update is required today.

Mental Health Assessments

The following assessments are provided based on your primary and secondary problems selected. A suicide risk screen is also included when recent thoughts or behaviors of harm are reported.

Suicide Risk Screen (CSSR-S)

Please answer the following questions about suicidal thoughts and behaviors.

1. In the past month, Have you wished you were dead or wished you could go to sleep and not wake up?

Yes No

2. Have you actually had any thoughts of killing yourself?

Yes No

3. Have you been thinking about how you might do this?

For example, thinking about a method without making a specific plan for when, where, or how you would act on it.

Yes No

4. Have you had these thoughts and had some intention of acting on them?

Yes No

5. Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?

Yes No

6. In your lifetime, Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Examples include taking pills, attempting to shoot or hang yourself, cutting yourself, collecting pills, obtaining a gun, going to a roof intending to jump, giving away valuables, or writing a suicide note.

Yes No

If YES to Question 6: Was this within the past three months?

Yes No

Interpretation: —

Trauma Screen (PC-PTSD-5)

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. Have you ever experienced this kind of event?

YesNo

In the past month have you experienced…

Total: — / 5 · Interpretation: —

Depression Screen (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Total: — / 27 · Interpretation: —

Mood Screen (RMS)

Please select one response for each question.

Total: — / 6 · Interpretation: —

Anxiety Screen (GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Total: — / 21 · Interpretation: —

ADHD Screen (ASRS Part A)

Select what best describes how you have felt and conducted yourself over the past 6 months.

Total: — / 6 · Interpretation: —

Insomnia Screen (ISI)

Please rate the current (last 2 weeks) severity of your insomnia problem(s), and answer the questions below.

Total: — / 28 · Interpretation: —

Stress Screen (PSS)

In the last month, how often have you felt or thought the following?

Total: — / 40 · Interpretation: —

Substance Use Assessment

Select all substances used in the past 3 months:

Nicotine (cigarettes, tobacco or vapes) Cannabis (weed, edibles, or vapes) Methamphetamines (meth, ice, speed, etc.) or Cocaine (powder or crack) Alcohol (beer, wine or liquor) Gabapentin (not prescribed) – Neurontin, pregablin Benzodiazepines (not prescribed) – Xanax, Klonopin, Valium

No substances selected

A response indicating current thoughts of self-harm or harm to others was selected. Please discuss with our mental health team during your appointment. If you are unable to keep yourself safe please Call 911 for immediate help or 988 for a 24/7 suicide hotline.

Updated Treatment Plan

Your treatment plan describes what you want to work on, how you will get there, and the care that will support you for the next 3 months.

1. Select your goals

Goals are an important part of continuing mental health treatment. Select the 3 goals that matter to you the most.

2. What challenges are making it harder to stay on track with treatment goals?

These challenges may affect appointments, taking medications, participating in treatment, or meeting my recovery goals. Select all that apply.

Barriers to care

I have no barriers in achieving my treatment goal

Unsafe or unstable Housing Food insecurity Transportation problems Need help applying for benefits (SNAP, Medicaid, Housing voucher, etc...) Challenges coordinating healthcare Lack of social support Legal/probation issues Challenges getting a stable job Childcare/caregiving responsibility Lack of phone/internet access Difficulty with living independently Other

Other challenge

3. What clinical interventions would support my goals?

These are pre-selected as the care that supports most treatment plans. Uncheck anything that does not apply to you.

Clinical intervention(s)

Evaluation and Medication Management by a psychiatric provider (MD/DNP) Psychotherapy and Psychological testing Group and/or family therapy Mental Health Case Management (to connect with social services) — to address the barriers you select

How often should this intervention be?

Weekly (Severe) Every 2 Weeks (Moderate) Monthly (Mild/Stable) Every 3 months (Maintenance/In-remission)

How long should the intervention be?

6 months (Acute) 12 months (Chronic)

My treatment plan will be supported by the following providers at Ultimate Care Behavioral Health Services.

Olivetta Uradu, MD Laura Madu, DNP

Signatures

The patient signs on the left. The provider reviewing this plan signs on the right.

Patient

Patient's Typed Legal Name

Date

Patient Signature

Provider

Provider Name & Credentials

Date

Provider Signature

Your 3 month treatment plan is complete.

Save your completed 3 month treatment plan to this device using the button below.

Consent to Save Protected Health Information

Selecting "Save 3 Month Treatment Plan" will create a PDF copy of this completed plan and save it to this device. At Ultimate Treatment Center, all devices are managed by our clinical staff in accordance with our Notice of Privacy Practices. This packet contains your protected health information, including mental health information protected by HIPAA and 42 CFR Part 2. Your information is not shared and protected.

I understand and consent to saving my protected health information to this device.

Need more help? Call 606-393-4632 for assistance.

Your 3 month treatment plan is saved.

A PDF copy has been saved to this device. Please let a member of our staff know that you have finished so they can review it with you.