CASE PLAN FOR DISCHARGE
[COURT] VERSION: Case Plan ______________________________________________________________
To stay stabilized, maintain compliance with treatment, and progress in my goals To respect my family member and living spaces
CASE PLAN OBJECTIVES AND CLIENT RESPONSIBILITIES
Patient’s Name: _________
This plan will address the circumstances that brought ________ under involuntary treatment. The patient and family member believe that with proper implementation of this plan all of the factors of grave disability and prior psychiatric history will become a serious issue in need of return to locked placement. If ________ fails to adhere to this plan, family member and ________will agree that family member will no longer provide housing and financial support and ___________will need to find his own means of providing food, clothing, and shelter.
Patient _________ OBJECTIVES
1. Attend Outpatient Therapy
Date: date when treatment with therapist can begin ________________________
Provider: which group[s] can provide services and name of organization ________________
Duration: How long does patient anticipate engaging in outpatient therapy
2. Attend Psychiatric Sessions
Date: date when treatment with psych doctor can begin ________________
Provider: which medical provider can provide services and name of doctor ________________
Duration: How long does patient anticipate engaging in outpatient psychiatry sessions ________________
Pharmacy: Where will patient get medications if prescribed
3. Maintain proper food and clothing
How: how will patient be able to keep their clothes clean and proper to wear? Will they work to keep their living space clean and organized.
4. Develop and share a specific Relapse Prevention plan
Plan for self. Patient will write up his own version of a relapse prevention plan and share it with the family member. If the family member sees that the patient is showing warning signs, then both parties agree to schedule an appointment with therapy or psychiatrist.
5. Do not involve your relatives or friends in attempts to relapse or intimidate with self harm threats
Patient understands that they should not engage or coerce family members in participating in dangerous activities to themselves or others. Patient understands the need to have a support network that understands the importance of stability and compliance.
CRISIS PLAN INFORMATION AND AGREEMENT
Plan For Continuing Medical Care when discharged
Should patient escalate or feel they cannot control their symptoms then they plan on using the medical treatment team below to help them out of a crisis. Patient agrees to involve family member in treatment and sign a ROI if admitted.
Medical Doctor: ________ Psychiatric Doctor: ________ Crisis Center: ________
Current Medication(s): _____________
Patient is currently prescribed the following:
Medication: Dose: Frequency: _____________
MEDICATION COMPLIANCE AGREEMENT
Treatment with Psychiatric Medications: Patient Agreement I, ________, understand and agree that
I will keep (and be on time for) all my scheduled appointments with the doctor. If changes need to be made I will call ahead. __________
I will participate in all other types of treatment that I am asked to participate in. __________ I will take my medication as instructed and not change the way I take it without first
talking to the psychiatrist or family member. __________
I will make sure I have an appointment for refills. If I am having trouble making an
appointment, I will tell a member of the treatment team immediately. __________
I will treat the doctor and family member respectfully. I understand that if I am
disrespectful or threatening to family member about medication, third party assistance may be withheld. __________
I will sign a release form to let the psychiatrist speak to family member. __________
I understand that the only exception to this is if I need an emergency change or stop to
medication due to dangerous life threatening side effects. __________
I understand that this is a process in finding the right medication. I promise to not give up or stop
treatment out of frustration. ________
I acknowledge that my illness is biological in nature and needs medication to keep the symptoms under control. Failure to take medication as prescribed will ensure a return of symptoms and psychosis. __________
FAMILY MEMBER AGREEMENT
Family member agrees to provide the following if the patient _______ adheres to their treatment,
outpatient therapy, and keeps their release of information open.
I agree to provide support and funds for food. ________
I agree to provide help with laundry and funds for new clothing if the patient respects the shared
living spaces by keeping them clean. ________
I agree to provide assistance and funds for housing if patient respects the home or apartment by not destroying anything, keeping the spaces clean, and allowing family member entry if there are concerns. ________
I agree to provide aid with helping patient getting to their medical appointments if the patient is struggling to get to appointments. ________
I promise to do my best to provide the above support as long as patient upholds his signed responsibilities._________________________ [date]
SHARED RELAPSE PREVENTION PLAN
Patient agrees to share and keep family member involved in their wellness recovery plan
My diagnosis is ______________
I understand that this a biological illness that requires treatment and vigilance for symptoms. I understand that this illness needs medication to keep the symptoms under control. I understand that even if I feel better it does not necessarily mean that I am cured. I still need to take medication even when asymptomatic.
My treatment team is
I have signed an ROI (release of information) for family member. __________ date
I agree to not rescind my ROI without asking family member. If I do I risk not having financial or housing support.
My medications are:
______________ dose ______________ dose ______________ dose
My warning signs of relapse are: _____________ _____________ _____________
My first step is to let family member know if I think I am struggling.
If family member thinks I am showing relapse signs I am willing to sit down and talk with them about my signs.
My second step is to contact my Dr. and let them know what symptoms I am having. I will allow family member attend the sessions and opine their observations.
I will allow my family member to check my medications to make sure I haven’t missed any.
I am willing to go to an extra session of therapy or outpatient if family member and I agree that it
would benefit me.
I promise to do my best to adhere to this wellness plan. _________________________ [date]
ACKNOWLEDGMENT BY PATIENT AND FAMILY MEMBER IN SIGNING THIS CASE PLAN, WE ACKNOWLEDGE THAT WE:
Worked together in this case plan development.
Agree to participate in the services and agreements outlined in this plan. Both have a copy of this case plan.
This plan can be revised together if elements need to be revised.
SIGNATURE OF Patient
________________________________________________________________ SIGNATURE OF FAMILY MEMBER DATE
__________________________________________________________________ SIGNATURE OF OTHER DATE