My Plan – shared care planning
Name:
NHI:
MY PLAN – kaupapa of shared care planning
This is collaborative record of my
Recovery Journey and the actions that I and my health team, supports,
and whānau have agreed to do to help promote my wellbeing, resilience, and quality of life.
This includes my
Wellbeing Plan, a summary of what I know I need to keep well and a roadmap for others
to support me in the way that is helpful when I need it.
This document has been developed in partnership with my team, and the goals stated are the stepping-
stones I need to support my wellbeing and to achieve what is a
Good Life for myself and my whānau.
MY WELLNESS TEAM – the key people working alongside me on this plan
Name
Service / Role in my wellbeing plan
Contact
MY PLAN COORDINATOR
This nominated person will be responsible for organising future My Plan hui and inviting attendees
under the Offical Information Act 1982
SIGN OFF – this plan has been agreed by the named key people
Date:
Released
Tangata Whaiora / Whānau
Support / NGO provider
Clinical Team / NASC
My Plan will be next reviewed on:
When:
Where:
Shared Care Plan | Te Moana ā Toi Mental Health & Addiction Services
My Plan – shared care planning
Name:
NHI:
WELLBEING PLAN
What I need to do daily or regularly and the resources I need to stay well and build my resilience
Taha Hinengaro – coping with distress, using
Taha Tinana – self-care, rest & relaxation, sleep,
treatment, mindfulness, being creative
being active, looking after my physical health
Taha Whānau – being with family, friends, and
Taha Wairua – expressing my identity, beliefs, and
social groups, talking with others, volunteering
spirituality, feeling connected, being in nature
under the Offical Information Act 1982
Released
Shared Care Plan | Te Moana ā Toi Mental Health & Addiction Services
My Plan – shared care planning
Name:
NHI:
ADVANCED CARE PLAN
What I need to do when I’m becoming unwell, and how others can support me
Becoming vulnerable – early warning signs
Action Plan – practical steps to address these
CRISIS PLAN – when I’m unwell, what is needed and what others can do to help
What others may notice:
Whānau & Social Support:
Community & Peer Support:
Clinical Team Interventions:
under the Offical Information Act 1982
POST-CRISIS RECOVERY – what is needed immediately after a crisis event to help my return to wellness
Released
Shared Care Plan | Te Moana ā Toi Mental Health & Addiction Services
My Plan – shared care planning
Name:
NHI:
WHAT A GOOD LIFE LOOKS LIKE FOR ME –
My description of a positive future I have for me, the life that I am hoping for, and what I am working
towards with my Care Team, Supports and Whānau
My Goal to Help Achieve This
Actions to help achieve my goal
Who will do this / when
What happened / progress
My Goal to Help Achieve This
Actions to help achieve my goal
Who will do this / when
What happened / progress
under the Offical Information Act 1982
Released
Shared Care Plan | Te Moana ā Toi Mental Health & Addiction Services
My Plan – shared care planning
Name:
NHI:
My Goal to Help Achieve This
Actions to help achieve my goal
Who will do this / when
What happened / progress
My Goal to Help Achieve This
Actions to help achieve my goal
Who will do this / when
What happened / progress
under the Offical Information Act 1982
My Goal to Help Achieve This
Actions to help achieve my goal
Who will do this / when
What happened / progress
Released
Shared Care Plan | Te Moana ā Toi Mental Health & Addiction Services
Name: NHI:
Address: Phone:
In-Patient Treatment
MENTAL HEALTH &
Please attach sticky label if available
Plan
ADDICTION SERVICES
MULTIDISCIPLINARY TEAM (MDT)
Contact
Start Date
End Date
Case Manager:
Psychiatrist:
Discharge Criteria (goals of service identified on admission)
Nurse/ Whai Neehi:
Psychologist:
Social Worker:
)
Occupational Therapist:
Pou Kokiri
A & D Counsellor
under the Offical Information Act 1982
ACUTE PLAN (to be completed with client at start of treatment plan)
Triggers / Early Warning Signs
Actions to be taken / Supports that can accessed
Non compliant with medication
Not attending to ADL
Released
Treatment Plan Form
(draft) May 2010
Page 1
Name: NHI:
Address: Phone:
In-Patient Treatment
MENTAL HEALTH &
Please attach sticky label if available
Plan
ADDICTION SERVICES
DATE
IDENTIFIED GOAL
PLANNED ACTIONS / INTERVENTION
PERSON
REVIEW
REVIEW / OUTCOME
(include risk/safety)
RESPONSIBLE
DATE
under the Offical Information Act 1982
Released
Add further treatment plan sheets as needed / following MDT reviews
SIGNED
Clinician: ________________________
Client: _________________________
Other: _________________________
Treatment Plan Form
(draft) May 2010
Page 2
Name: NHI:
Address: Phone:
In-Patient Treatment
MENTAL HEALTH &
Please attach sticky label if available
Plan
ADDICTION SERVICES
DATE
IDENTIFIED GOAL
PLANNED ACTIONS / INTERVENTION
PERSON
REVIEW
REVIEW / OUTCOME
(include risk/safety)
RESPONSIBLE
DATE
under the Offical Information Act 1982
Released
Add further treatment plan sheets as needed / following MDT reviews
SIGNED
Clinician: ________________________
Client: _________________________
Other: _________________________
Treatment Plan Form
(draft) May 2010
Page 3
Name: NHI:
Address: Phone:
In-Patient Treatment
MENTAL HEALTH &
Please attach sticky label if available
Plan
ADDICTION SERVICES
DATE
IDENTIFIED GOAL
PLANNED ACTIONS / INTERVENTION
PERSON
REVIEW
REVIEW / OUTCOME
(include risk/safety)
RESPONSIBLE
DATE
under the Offical Information Act 1982
Released
Add further treatment plan sheets as needed / following MDT reviews
SIGNED
Clinician: ________________________
Client: _________________________
Other: _________________________
Treatment Plan Form
(draft) May 2010
Page 4
Admission date:
Patient Label
In-Patient
48 Hour
Staff at Te Whare Maiangiangi will promote mental
Legal Status on
Initial
wellbeing by providing client- centered care based on
admission:
the Recovery model
Care Plan
Identified risks
Outcome
Outcome
Mental Health Care
Action
Variation
recorded in
recorded in
Needs
N/N
N/N
Day 1
Day 2
Maintain safety in the •
Assess current risks and update
least restrictive
risk assessment
manner
• Institute congruent level of
observation
Monitor mental state
• Assess mental state and document
observations through 24 hr cycle
• Inform clinicians of significant
changes to mental state
Psycho-pharmacy
• Administer medication as
appropriate to
prescribed
condition
• Monitor and report efficacy
Collaboration and
• Maintain authentic therapeutic
partnership
presence based on trust, warmth,
empathy and immediacy
• Utilise micro-counselling strategies
as appropriate
Physical Care needs
Action
Variation
Physical well-being
•
Baseline recordings as indicated
•
Management of Falls Risk
•
Physical examination and daily
recordings
• Medications/physical care
under the Offical Information Act 1982
appropriate to condition
Healthy & balanced
•
Monitor nutritional status and
nutritional intake
encourage healthy eating
• Dietician referral as appropriate
Healthy & balanced
Monitor sleep pattern and encourage
sleep/rest pattern
sleep hygiene
Social Care Needs
Action
Variation
Released
Maintenance of
Encourage independence in activities
personal autonomy
of daily living
Maintain links with
Facilitate visits from significant others
significant others
as indicated by client
Limit economic or
Ensure relevant medical
occupational harm 2˚ certificates/SW benefit applications are
to hospitalisation
provided
Cultural safety
Individual cultural beliefs are respected
and accommodated
Spirituality
Facilitate access to spiritual advisors
as appropriate
Signed-
Clinician: ______________________
Client: ________________________
Version: 3 Issued: May 2016
Page 1 of 1
MHS Inpt TP 48 hour
[[pgname_P]] [[psname_U]]
NHI:
[[pnhi_U]]
[[padd1_P]]
DOB:
[[pbdate_L]]
[[padd2_P]]
PH:
[[ptelep_U]]
TREATMENT PLAN
[[padd4_U]]
MENTAL HEALTH
& ADDICTION SERVICES
MULTIDISCIPLINARY TEAM (MDT)
Start Date
End Date
Case Manager:
Psychiatrist:/Paediatrician
Summary of Needs / Issues (identified in Comprehensive Assessment)
Nurse/ Whai Neehi:
Psychologist:
Social Worker:
Occupational Therapist:
Pou Kokiri
A & D Counsellor
DISCHARGE PLAN
Discharge / Exit Criteria
Discharge Need(s) (identified at final review)
Responsibility / Referred to
Date
under the Offical Information Act 1982
Released •
•
Version: 1 Issued: October 2022
Page 1 of 3
MHAS: Form TPComm1
[[pgname_P]] [[psname_U]]
NHI:
[[pnhi_U]]
[[padd1_P]]
DOB:
[[pbdate_L]]
[[padd2_P]]
PH:
[[ptelep_U]]
TREATMENT PLAN
[[padd4_U]]
MENTAL HEALTH
& ADDICTION SERVICES
•
•
DATE
IDENTIFIED NEED / GOAL
ACTIONS / INTERVENTION
SIGNED
Date Reviewed Changed
under the Offical Information Act 1982
•
Released
Version: 1 Issued: October 2022
Page 1 of 3
MHAS: Form TPComm1
[[pgname_P]] [[psname_U]]
NHI:
[[pnhi_U]]
[[padd1_P]]
DOB:
[[pbdate_L]]
[[padd2_P]]
PH:
[[ptelep_U]]
TREATMENT PLAN
[[padd4_U]]
MENTAL HEALTH
& ADDICTION SERVICES
•
•
•
Client Copy:
Accepted
Declined
if declined, give reason: _________________________________________________________
under the Offical Information Act 1982
Released
Version: 1 Issued: October 2022
Page 1 of 3
MHAS: Form TPComm1
Name: NHI:
Address: Phone:
TREATMENT PLAN
MENTAL HEALTH
& ADDICTION SERVICES
Please attach sticky label if available
[[pgname_P]] [[psname_U]]
DOB: [[pbdate_L]]
NHI: [[pnhi_U]]
ADDRESS: [[padd1_P]] [[padd2_P]], [[psubrb_P]], [[padd4_P]]
Date reviewed
MULTIDISCIPLINARY TEAM (MDT)
Start Date
End Date
Case Manager:
Psychiatrist:
Summary of Needs / Issues (identified in Comprehensive Assessment)
•
Nurse/ Whai Neehi:
•
Psychologist:
•
Social Worker:
Occupational Therapist:
Pou Kokiri
A & D Counsellor
under the Offical Information Act 1982
DISCHARGE PLAN
Discharge / Exit Criteria
Discharge Need(s) (identified at final review)
Responsibility / Referred to
Date
•
•
Released
•
•
•
•
Name: NHI:
Address: Phone:
TREATMENT PLAN
MENTAL HEALTH
& ADDICTION SERVICES
Please attach sticky label if available
Relapse Prevention Plan (completed by)
under the Offical Information Act 1982
Released
Name: NHI:
Address: Phone:
TREATMENT PLAN
MENTAL HEALTH
& ADDICTION SERVICES
Please attach sticky label if available
DATE
IDENTIFIED NEED / GOAL
ACTIONS / INTERVENTION
SIGNED
Date Reviewed Changed
Clinician:
Client / Family:
Clinician:
Client / Family:
Clinician:
Client / Family:
under the Offical Information Act 1982
Client Copy:
Accepted
Declined
if declined, give reason:
_________________________________________
Released
This care plan is a guide to all staff who are involved in patient care
MULTI DISIPLINARY GOALS
Detailed interventions are noted as documented on other forms e.g. Wound Care plan, Restraint Care plan,
Patient Label
AND CARE
Adult admission care plan
MANAGEMENT PLAN
Evaluation of patient progress against goals will be documented in clinical notes
Care plan should be reviewed and updated when there are changes in patient status
Plan to be presented to family and signed by family member
NEED FOR CHANGE: (identify any current
GOALS: (Achievable positive outcome
INTERVENTIONS: (methods, techniques,
EVALUATION: (Review of interventions and
EVALUATION: (Review of interventions and
EVALUATION: (Review of interventions
No.
DATE
problems / difficulties which require intervention and/or
fol owing intervention)
procedures etc. used to achieve goals)
goal outcomes)
goal outcomes)
and goal outcomes)
treatment during admission)
Safety & Risk i.e. to self or others;-self
neglect, self-harm, suicide & behavioural risk.
Signature:
Date:
Date:
Date:
Sign:
Sign:
Sign:
Mental Health Symptoms :i.e. low mood,
anhedonia, amotivation /volition, mania ,
vegetative state, ineffective coping , altered
cognition & thought processes, impaired
judgement, spiritual distress , altered nutrition ,
altered self esteem , social isolation.
Signature:
Date:
Date:
Date:
Sign:
Sign:
Sign:
Mental Health Symptoms i.e.
Sensory /perceptual changes-hallucinations ,
altered thought processes , delusions ,
Catatonia impaired communication, negative
symptoms
Signature
Date:
Date:
Date:
Sign:
Sign:
Sign
under the Offical Information Act 1982
Mental Health Symptoms i.e. increased
anxiety-autonomic signs , somatic symptoms
sensory/muscular , panic attacks- , poor coping
mechanism, , social isolation, poor impulse
control –obsessive compulsive behaviours
Signature:
Released
Date:
Date:
Date:
Sign
Sign
Sign
Dementia & BPSD Symptoms i.e.
ABC/ Agitation Chart to be completed
cognitive disturbance memory ;Apraxia, aphasia
(note on chart any changes in meds or
agnosia, , poor self-care poor sequencing ,
behavioural approach)
perceptual disturbance , motor function.
Signature
Date:
Date:
Date:
Sign
Sign
Sign
Dementia & BPSD Symptoms
ABC/ Agitation Chart to be completed
Aggression & agitation, Non-compliance to
(note on chart any changes in meds or
medication, anxiety mood disturbance
behavioural approach)
personality changes, altered sleep.
Signature :
Date:
Date:
Date:
Sign :
Sign
Sign:
Other .i.e. EPS, noncompliance to medication
substance abuse. Eating disorder , delirium, pain
Signature:
Date:
Date:
Date:
Sign :
Sign:
Sign:
Discussed with client/
Yes
No
Client or Family member signature:
family/EPOA :
under the Offical Information Act 1982
Print Name:
Date:
Released
Name:
NHI:
Address:
WELLNESS PLAN
MICAMHS YOUTH TEAM
DOB:
Ethnicity:
Responsible Clinician:
Legal Status:
Attach patient label
To be completed with Young Person/Whanau
Date: For:
Admission
Review
Discharge
IMPORTANT CONTACTS & SUPPORT PEOPLE:
During work hours MICAMHS 0800333061 and after hours 0800
Family/Whanau:
800508; Tauranga Police: 111 GP:
Clinician:
Other:
Psychiatrist:
Other:
I know I am well when I am [WELLNESS] – school, work, home, social, health and wellbeing
The situations and things that have caused me to become unwell are [TRIGGERS] – situational: school, work,
home, family, relationships, social, substance use
Signs I am becoming unwell are [EARLY WARNING SIGNS] – feelings, thoughts (what goes through your head),
sleep, delusions/hallucinations, eating habits, behaviour (social withdrawal, snapping at others etc.), physical sensations
(breath quickens, dizzy etc.)
under the Offical Information Act 1982
If I feel I am becoming unwell I can [RELAPSE PREVENTION] -
medication compliance, reduced stress, family/social
support, environmental strategies, spiritual & cultural support, lifestyle
What I can do:
Distraction/relaxation activities/coping statements:
1.
2.
Released
What other people can do to help me:
1.
2.
What can be done to support my family:
1.
2.
MEDICATION PRESCRIBED
Clinician Name:
Clinician Signature:
Name of Young Person/Whanau:
__________________
Young Person/Whanau signature
:
_______
Version: 1 Youth Team MICAMHS: Issue date: May 2023
Mental Health and Addiction Service – Child and Youth
Tauranga Hospital
Cameron Road, Private Bag 12024
Tauranga NEW ZEALAND
PARTNERSHIP
KEYWORKER:
DATE:
NAME
NHI
Developmental History:
Pregnancy:
Birth:
under the Offical Information Act 1982
Released
Neonatal Period (1st four weeks):
AU:2534 TY:4025
Partnership template 2018
2
Maternal Health:
Infancy: (First Year, Feeding, Sleeping, Motor Behaviour, Temperament)
under the Offical Information Act 1982
Milestones: (Smiling, Sitting, Standing, Walking, Crawling, Talking, Toileting, Puberty)
Released
Partnership template 2018
3
Significant Events: (Separations, Bonding, attachment etc)
Relevant Medical/Psychiatric History:
Medical:
under the Offical Information Act 1982
Released
Partnership template 2018
4
Psychiatric:
Personality and Temperament:
under the Offical Information Act 1982
Released
Partnership template 2018
5
Family History:
Family Structure/Genogram:
Family Psychiatric History:
under the Offical Information Act 1982
Released
Partnership template 2018
6
Family Medical History:
Social Situation: (Living circumstances, financial situation, supports, significant stressors)
under the Offical Information Act 1982
Released
Partnership template 2018
7
Cultural Factors:
Personal History
Peer Relationships:
under the Offical Information Act 1982
Hobbies and Activities:
Released
Partnership template 2018
8
Cultural Identification:
Spiritual Beliefs:
Self Esteem:
under the Offical Information Act 1982
Any other relevant information about the client/family:
Released
Partnership template 2018
9
Assessor Name: Signed:
Date:
under the Offical Information Act 1982
Consent forms
Care Plan
Risk Assessment
HONOSCA
Released
RISK ASSESSMENT & TRANSITION PLAN (R.A.T.)
Name:
NHI:
DOB:
Risk Assessment (Risks and Risks factors):
Date of Risk Assessment:
Assessor Name and Designation:
Domains
Current: 0-8 weeks
Historical: >8 Weeks
RISK TO SELF:
Consider: Suicidal ideation, plans,
intent, previous attempt, access to
means, self-harm, drug/alcohol use,
truancy, self cares (sleep, appetite,
physical conditions/ chronic il ness),
relationship break up, cognition, low
self-esteem, mood, hopelessness,
impulsivity, mental health disorder,
social disengagement, school failure.
RISK TO OTHERS:
Consider: Violence, aggression,
bullying, sexualised behaviour,
conduct, criminal activities, damage to
property, availability of weapons
RISK FROM OTHERS:
Consider: Bullying,
physical/sexual/emotional abuse,
Neglect, Peer pressure.
FAMILY/ENVIRONMENTAL RISKS:
Consider: Family violence/dynamics,
parental conflict/divorce, carers
mental/physical health, Living
environment (overcrowding/exposure
to drugs/alcohol/gangs/guns/ violence/
sexual activity etc), death, loss, grief,
financial situation.
under the Offical Information Act 1982
Family history suicide.
Court/Police issues.
Strengths and Protective Factors (Consider: Locus of control, self-esteem, parental presence and connectedness,
connected to school, peers and other adults):
Released
Risk Formulation: (Use 5P’s; Presenting, Predisposing, Precipitating, Perpetuating, Protective factors):
Presenting:
Predisposing:
Precipitating:
Perpetuating:
Protective:
OVERALL LEVEL OF RISK: LOW MEDIUM HIGH
HONOSCA SCORE: _______ Date_____________
Youth Wellness Plan
Ideal y this plan is to be completed by the young person and their legal guardian
(parent/carer). The young person and their legal guardian are responsible for ensuring that
this young person and others around them remain safe.
Triggers
Unhelpful Behaviours
List situations or events that increase
List behaviours that do not help your
your risk of engaging in unhelpful
wellbeing:
behaviours.
1. .
1. .
2. .
2. .
3. .
3. .
4. .
4. .
5. .
5. .
6. .
6. .
7. .
7. .
8. .
8. .
9. .
9. .
10. .
10. .
under the Offical Information Act 1982
Youth Support Team
Helpful Behaviours
List the people and organisations
List behaviours that help you to stay
helping you stay well.
safe and well.
Name: _______________________
1. .
Released
Phone: _______________________
2. .
Name: _______________________
3. .
Phone: _______________________
4. .
Name: _______________________
5. .
Phone: _______________________
6. .
Name: _______________________
7. .
Phone: _______________________
8. .
9. .
Mental Health Crisis Team (24/7): 0800 800 508
10. .
Youthline: 0800 37 66 33, free txt 234
Child/Adolescent Mental Health: 5798380 or
0800 333 061
If an emergency call ‘111’
Client Objectives, Plan, Engagement (COPE)
My Choice Goal (s):
Things I have been working on:
The things I have achieved since I
first came here:
Things that have supported my
wellbeing:
Things I can keep doing to support
my wellbeing:
My Medications:
under the Offical Information Act 1982
Medication
What it does
Dose
When and how to take it
Name
Released
Signature _______________________ Date ____________________________
Document Outline
