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

Form MHSA015 is a Florida Department of Juvenile Justice form also known as the "Initial Mental Health/substance Abuse Treatment Plan - Sample". The latest edition of the form was released in October 1, 2014 and is available for digital filing.

Download an up-to-date Form MHSA015 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 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
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