DJJ Form MHSA016 "Individualized Mental Health/Substance Abuse Treatment Plan - Sample" - Florida

Form MHSA016 or the "Individualized Mental Health/substance Abuse Treatment Plan - Sample" is a form issued by the Florida Department of Juvenile Justice.

The form was last revised in October 1, 2014 and is available for digital filing. Download an up-to-date Form MHSA016 in PDF-format down below or look it up on the Florida Department of Juvenile Justice Forms website.

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Download DJJ Form MHSA016 "Individualized Mental Health/Substance Abuse Treatment Plan - Sample" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
SAMPLE
INDIVIDUALIZED MENTAL HEALTH/SUBSTANCE ABUSE
TREATMENT PLAN
Youth’s Name
DOB
Sex
Race
JJIS #
Facility Name
1. DSM-IV-TR or DSM-5 Diagnoses and Symptoms
DSM-IV-TR Diagnoses
Symptoms
Axis I
Axis II
Axis III
Axis IV
Axis V (GAF)
DSM-5 Diagnoses
Symptoms
2. Mental Health and/or Substance Abuse Treatment Goals:
M e n t a l H e a l t h T r e a t m e n t G o a l s :
:
S u b s t a n c e A b u s e T r e a t m e n t G o a l s
Rule 63N-1, F.A.C.
MHSA 016
October 2014
Page 1 of 2
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
SAMPLE
INDIVIDUALIZED MENTAL HEALTH/SUBSTANCE ABUSE
TREATMENT PLAN
Youth’s Name
DOB
Sex
Race
JJIS #
Facility Name
1. DSM-IV-TR or DSM-5 Diagnoses and Symptoms
DSM-IV-TR Diagnoses
Symptoms
Axis I
Axis II
Axis III
Axis IV
Axis V (GAF)
DSM-5 Diagnoses
Symptoms
2. Mental Health and/or Substance Abuse Treatment Goals:
M e n t a l H e a l t h T r e a t m e n t G o a l s :
:
S u b s t a n c e A b u s e T r e a t m e n t G o a l s
Rule 63N-1, F.A.C.
MHSA 016
October 2014
Page 1 of 2
3. Mental Health and/or Substance Abuse Treatment Objectives and Methods/Interventions
Symptoms
Objectives
Methods/Interventions
Target
(Measurable and Achievable)
(Duration, Amount and Frequency)
Dates
(
4. Psychiatric Services:
F o r y o u t h s r e c e i v i n g p s y c h i a t r i c c a r e , r e c o r d 1 . P s y c h o t r o p i c
m e d i c a t i o n s c u r r e n t l y p r e s c r i b e d ; a n d 2 . F r e q u e n c y o f m o n i t o r i n g b y a p s y c h i a t r i s t ) .
(
5. Youth and family strengths and needs:
S t r e n g t h s a n d n e e d s w h i c h m a y e f f e c t h i s / h e r
s u c c e s s i n a c h i e v i n g m e n t a l h e a l t h / s u b s t a n c e a b u s e t r e a t m e n t g o a l s . )
Youth’s Signature/Date
Parent/Guardian’s Signature/Date
Mental Health/Substance Abuse Clinical Staff’ Signature/Date
Treatment Team Member Signature/Date
Licensed Mental Health/Substance Abuse Professional’s
Treatment Team Member Signature/Date
Signature/Date
Treatment Team Member Signature/Date
Treatment Team Member Signature/Date
Rule 63N-1, F.A.C.
MHSA 016
October 2014
Page 2 of 2
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