Sample Individual Treatment Plan (ITP)
Client Name: Tony

Date of Plan 7-04

Client ID: 1234567________

Individuals Involved in the development of the ITPClient/Agency/Title/Family Member/Other (specify)

TonyClientMark

Best ARMHS Mental Health Practitioner

John

Best ARMHS Nurse

RebeccaDRS Counselor

Dimetrius

Client’s brotherLynn

County Case Manager

Other

Date of most current diagnostic assessment: Schizoaffective Disorder 6-30-04 redetermination
Problems/Needs identified in the diagnostic and functional assessment:1) Tony reports that he has gone off of medication 3x’s in the past three years when he was psychiatrically stable to “fit in”
with his peers and to lose weight he gained on Zyprexa. “I’m losing time, I’m losing my life.” Doesn’t understand how
medication works and 80 lb weight increase has decreased mobility and energy.
2) Tony has lived independently once, but lost apartment due to environmental safety issues (clutter). Identified lack of safety plans
and safety resources.
3) “I don’t have any friends but the ones that use drugs. When I’m not with them I stay at home and watch TV or sleep. I want
A sense of community. ” “I want to be a nice guy and sometimes I do things that I know I shouldn’t do or can’t do, but I don’tknow how to get out of it.”Strengths and resources:
1) Has membership to the YWCA through local community support program; psychiatrically stable for six months after committed toRTC and released six months ago.
2) Indicated a desire to live in shared housing as a “practice step” to living independently in the future.
3) Has started going to “rap poetry” events and likes the “atmosphere and friendliness”.
4) He has many good social skills. He is polite and respectful. He reads the paper daily and likes to talk politics, engaging and warm.
Well liked by peers and professionals in mental health system. Well groomed and takes pride in his personal appearance.
“People judge you by how you look. I don’t want to look intimidating or messed up. I want people to like me.”5) Has enrolled in Barber College and will begin the first week of September.

Cultural considerations, resources, supports and needs:
Recipient identified the stigma of mental illness especially as a young male in the African American community. “Brothers” in thechurch support him as well as his blood brothers. They do community building and he likes to be “positive and healthy”. Church
members are older and he wants a peer group close to his age.

Goals, Objectives and Strategies(objective must be outcomes andmeasurable)(strategies define actions to be taken andwho does what)
Goal #1A: Improving my health and mental illness.
(Illness management)
Objective: I will name my symptoms of schizoaffective
disorder, name the medications and what symptoms
theytreat and the potential side effects of the medications Itake.
Strategies: I will meet with the ARMHS nurse weekly.
I will read information that she gives me and ask
questions. I will learn about how the medications
work and what to tell my psychiatrist by role playing
with the nurse.
Goal #1B: Improving my health and mental health( Illness management, health management)
Objective: I will exercise 3X’s a week for 20 minutes
andmark my calendar each day that I do this.
Strategies: Exercises that I can choose from: I can go tothe YWCA. I can shoot baskets with the other guys at
XYZ CSP, with staff or my family. I can walk six
blocks to XYZ CSP. I will talk to the ARMHS
nurse about my exercise and eating.
Goal #2: Keeping myself safe and where I live safe.
(Independent living skills, maintaining housing)
Objective: I will make a safety plan and use it so that I
have no unsafe incidents over the next six months
whereI am living.
Strategies: I will talk to my ARMHS worker about pastIncidents and come up with safe ways to handle theproblems that I had. I will make a list of people andresources to call in an emergency or when I don’t knowwhat to do and put it by my phone. I will role play
unsafe or emergency situations with my ARMHS
worker.

Med.
Nec.
Y/N

Time Frame to beachieved

Type of Service

Frequency(of service
contact, lengthand frequency)

Person (s)Responsible(recipient andproviders)

Yes

Goal 1A: by
10/3/04

Medication
education/IMR
1 to 1

Goal 1A :weekly
until Tonyunderstands meds
etc. and thenevery other week.

Tony andBest ARMHS
nurse.

Yes

Goal 1B: by 8/4/04
to have worked up
to 3X’s a week.

1 to 1
Skills Programming(helping Tony setup a plan forexercising)Goal #1B:
ARMHS nurse
weekly contacts
and then every
other week as
exercise isestablished.

By 1/3/05 when I
move into
independenthousing.

1 to 1’s
Goal #2 weekly
Skills Teaching,visits withSkills strengthening, ARMHS worker
Resource
acquisition anddevelopment.
Community
intervention asneededYes

Tony and BestARMHS nurse

Tony and BestARMHSworkerMedNecY/NTime Frame

Type of Service

Frequency

Persons
Responsible

Goal #3A: Making friends who don’t use (Use of drugs
and alcohol, social functioning and leisure)
Objective: I will make a new acquaintance who I cancall
A friend and will tell his/her name and social contact tomy ARMHS worker.
Strategies: I will make a list of places to go where I canhave fun without using. I can ask other members ofXYZ CSP. I can call AA. I can attend “AfricanAfrican American Perspectives on Mental HealthGroup” and talk about it with other young guys,
I can go to the drop in center. I can volunteer. I canask people at church what they do.

YesOrBestARM
HS

Goal #3A By
1/3/05

Resourceacquisition(where to go to meetpeople)

Goal #3A:
Weekly 1 to 1’s
and weekly
groups with BestARMHS staff
specializing insocialization andinterpersonalcommunication

Goal #3A: Tonyand Best
ARMHS
Staff

Goal #3B: Standing up for myself and not let others take
Advantage of me. (Use of drugs and alcohol, socialfunctioning)
Objective: I will not use any drugs or alcohol for thenext six months reported weekly by me, my family,
XYZ CSP staff weekly to my ARMHS worker.
Strategies: I sill say “no” to others who use drugs or ask
me to do things I feel are wrong. I will role play withstaff. I will talk about difficult situations withwith staff. I will try AA and go to the MI/CD class at
Best ARMHS. I will participate in AssertivenessGroup at XYZ CSP.

Yes forBest
ARM
HS

Goal #3B: Weekly
MI/CD groups at
Best ARMHS
Weekly 1 to 1’swith ARMHSstaff.

Tony andARMHS staff,XYZ CSP
program groupweeklyXYZ CSP staff
and my family

Goals, Objectives and Strategies

Goal 3B: 180 days
with no use orapproximately
through 1/3/05.
Reported weekly
to ARMHS staff.

MI/CD group at
Best ARMHSXYZ assertivenessgroup
AA group
participation
Community
intervention withbrother and asneededXYZ CSP

Goals, Objectives, Strategies
Goal #4: Being successful in Barber College (Vocationaland illness management)
Objective: I will follow a ‘healthy schedule” five days aweek (Monday through Friday) and mark it on mycalendar daily to show my Dad and ARMHS worker.
Strategies: A “healthy schedule” includes going to bed
and getting up at the same time, taking my meds everyday, exercising at least three times a week and getting outof the house each day for programs and appointments.
I will attend activities and groups at XYZ CSP
When I feel stressed that I am doing too much
I will talk to my ARMHS worker before I get toooverwhelmed. Monthly meetings with DRS worker

MedNecY/N
Yes forBestARM
HSTime Frame

Type of Service

Goal #4: To beSkills teachingachieved by 9-3-04. (Planning andDaily self reportScheduling)each day M-F oncalendar in room.

Frequency

PersonsResponsible

1 to 1’s weeklyTony, Best
with Best ARMHS ARMHS
worker andworker,
weekly vocational
support group

Activities groups

XYZ CSP
activitiesXYZ CSP,

Vocational supportgroup(referral to bemade)DRS CounselorReferral (s) will be made to (if needed):

Person (s) responsible for making referral (s):ABC Work support group

Rebecca (DRS Counselor)

Time Frame

Coordination of Services – identify other services recipient is receiving and explain how the services are being coordinated):
Rule 79 Case Manager Mark __________, is coordinating services, XYZ CSP, Rebecca ________ of DRS.
This plan was developed with the participation of the recipient or legal representative (Identify):
Yes___
No____ (Specify reason): ______________________________________________________________________________________________

Signatures:_______________________________________________/_______________
Recipient

Date_______________________________________________________ /___________________
Recipient’s Legal Guardian (if applicable)
Date________________________________________________________ /___________________
Mental Health Professional
Date
Or Mental Health Practitioner (individual who wrote plan)________________________________________________________ /___________________
Mental Health Professional
Date(Individual providing clinical supervision in the development of the plan and determination of medical necessity)_________________________________________________________/___________________
Other
Date

Plan Update: This plan must be updated at least every six months or more often when there is a significant change in the recipient’s situation orfunctioning, or in services or service methods to be used, or at the request of the recipient or the recipient’s legal guardian.

Proposed Date for ITP meeting to update plan: __________________
A copy of the plan must be given to the recipient and/or legal guardian. The provide is responsible to develop and maintain clear progress notes in therecipients file related to service contacts and outcomes of the goals specified in this plan.