DJJ Form MHSA015 "Initial Mental Health/Substance Abuse Treatment Plan - Sample" - Florida

What Is DJJ Form MHSA015?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DJJ Form MHSA015 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form MHSA015 "Initial Mental Health/Substance Abuse Treatment Plan - Sample" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
SAMPLE
INITIAL MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT PLAN
Youth’s Name_______________________________________________________________
DOB________________ Sex______ Race______ JJIS No. __________________________
Facility Name ___________________________________________Circuit ______________
1. Reason for Mental Health/Substance Abuse Treatment:
2. Initial Diagnostic Impression or Presenting Symptoms:
Initial DSM-IV-TR or DSM-5 Diagnoses
DSM-IV-TR Diagnoses
Axis I
Axis II
Axis III
Axis IV
Axis V (GAF)
DSM-5 Diagnoses
Presenting Symptoms
3. Initial Treatment Methods
: (Describe treatment methods, duration, amount and frequency of mental health
and/or substance abuse services. For youths receiving psychiatric care, record: 1. Psychotropic medications
currently prescribed; and 2. Frequency of monitoring by a psychiatrist).
4. Initial Treatment Goals and Objectives
Goal:
Objective:
Goal:
Objective:
Goal:
Objective:
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 Professional’s or CAP Signature/Date
Treatment Team Member Signature/Date
Rule 63N-1, F.A.C.
MHSA 015
October 2014
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
SAMPLE
INITIAL MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT PLAN
Youth’s Name_______________________________________________________________
DOB________________ Sex______ Race______ JJIS No. __________________________
Facility Name ___________________________________________Circuit ______________
1. Reason for Mental Health/Substance Abuse Treatment:
2. Initial Diagnostic Impression or Presenting Symptoms:
Initial DSM-IV-TR or DSM-5 Diagnoses
DSM-IV-TR Diagnoses
Axis I
Axis II
Axis III
Axis IV
Axis V (GAF)
DSM-5 Diagnoses
Presenting Symptoms
3. Initial Treatment Methods
: (Describe treatment methods, duration, amount and frequency of mental health
and/or substance abuse services. For youths receiving psychiatric care, record: 1. Psychotropic medications
currently prescribed; and 2. Frequency of monitoring by a psychiatrist).
4. Initial Treatment Goals and Objectives
Goal:
Objective:
Goal:
Objective:
Goal:
Objective:
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 Professional’s or CAP Signature/Date
Treatment Team Member Signature/Date
Rule 63N-1, F.A.C.
MHSA 015
October 2014