Name:
DOB:
NHI:
Address:
COMMUNITY MENTAL HEALTH
AND ADDICTION SERVICES
Phone:
Mobile:
Assessment & Treatment Plan
Written By:
Current Key Worker:
Role:
Psychiatrist/Medical:
Date of Assessment:
Community or Other Worker:
GP:
Cultural Identity
Whanau/family Contacts
1982
If Maori include Iwi/Hapu
Name
Preferred Language
Phone
Act
Gender
Address
Marital status
Email
Communication
Client’s Primary:
Barriers?
Nominated
Interpreter required?
Caregivers Other:
Legal Status
Information
Children/
(MHA, CJA, CYFS)
dependents
Power of Attorney
Detail client consent
for release of
Other contacts
Offical
information
(school etc)
the
Source of Referral
under
Reasons for Referral
Presenting
Complaints
History of Presenting
Complaints Released
Psychiatric History
Forensic History
Medical History
Medication
Allergies
MHS Assessment and Treatment Plan (V05: Dec 2015)
Page 1 of 3
Substance Use
Family Medical
History
Family Psychiatric
History
Personal and Social
History
Personality
Cultural Assessment
Strengths
1982
Mental State
Act
RISK ASSESSMENT
1/ Risks to Self
History of Harm to Self
Information
What Happened
Mental State/Condition
Environmental Factors
Outcome
Offical
Current Suicidal Behaviour
the
What Happened
Mental State/Condition
Environmental Factors
SUMMARY
of Suicide Risk
under
2/ Risks to Others
History of Risks to Others
Released
What Happened
Mental State/Condition
Environmental Factors
Outcome
Current Risks to Others
Describe threats/verbal/
physical/neglect
Mental State/Condition
Environmental Factors
SUMMARY
of Risks to Others
MHS Assessment and Treatment Plan (V05: Dec 2015)
Page 2 of 3
3/ Vulnerability to Harm and Exploitation
History of Vulnerability
What Happened
Mental State/Condition
Environmental Factors
Outcome
Current Risks of Harm and Exploitation
Describe current
Vulnerabilities
Mental State/Condition
Environmental Factors
SUMMARY
of Risks of Vulnerability
1982
Risk of Loss to Follow Up:
Act
Summary/Formulation
Information
Working Diagnosis
Offical
the
Management Plan/Whakaora Date: Review Date:
under
Issue
Short term management
Medium to Long term
Risk management
Client’s specific
requests for
management or
Released
Advance Directive
Whanau consultation
Add more rows as needed
Cut and paste a copy below of the Management table when Plan is reviewed.
Ensure Client’s Recovery plan is updated if Management Plan changes
MHS Assessment and Treatment Plan (V05: Dec 2015)
Page 3 of 3
Name:
DOB:
NHI:
Address:
COMMUNITY MENTAL HEALTH
AND ADDICTION SERVICES
Phone:
TRK Recovery / Transition Plan
Mobile:
(Client owned document)
Date Completed:
Written By:
Role:
If you have any concerns or queries please contact Mental Health Services Crisis Service
Monday to Friday - 8.00am – 4.30pm
1982
Whangarei: Phone: 430 4101 - Ext 3501
Mid North: Phone (09)404-2858 Ext 5871
Act
Kaitaia: Phone (09) 4080010 – Ask for Mental Health crisis service
Weekends and after hours
Mental Health Line 0800 22 33 71
What are my priorities and Personal Goals
Information
1.
2.
3.
Offical
4.
Actions towards my Goals / Things I have be
the
en working on
under
The things that I have achieved since I first started working with the service:
.
Released
Who else wil be involved? Include names and numbers (NGO, family/whanau etc).
.
Recovery Plan
Page 1 of 3
Things I can do to stay wel or that have supported my well being
Things that may make me unwell
My early warning signs
.
1982
Act
When things are breaking down / My just-in-case plans
Information
If I need support I can contact
Urgent:
Offical
the
Non-urgent:
under
My Medications
Medication Name
What it does
Dose
How to take it
When to take it
Released
Recovery Plan
Page 2 of 3
My Appointments
Appointment with
Date
Phone Number
1982
Act
My plans for follow-up with other services:
Information
What I need from other services:
Offical
the
under
Copy Provided to Client :
Yes / No
Date
Released
Recovery Plan
Page 3 of 3
Name:
DOB:
NHI:
Address:
COMMUNITY MENTAL HEALTH
AND ADDICTION SERVICES
Phone:
Recovery Plan
Mobile:
(Client owned document)
Date Completed:
Written By:
Role:
If you have any concerns or queries please contact Mental Health Services Crisis Service
Monday to Friday 8.00am – 4.30pm
1982
Whangarei area: (09) 430-4101. Extn: 3537
Kaipara area: (09) 439-3330. Extn: 65401
Mid North / Kaikohe: 0800 643 647
Act
Far North: (09) 408-9187
After hours: 0800 as normal
Weekends and after hours
Mental Health Line 0800 22 33 71
Team
Name
Phone
Support people
Phone
Information
Keyworker
GP
Offical
Consultant
Other
the
What are my priorities (Goals)
under
1.
2.
3.
4.
Agreed actions
Released
Who else wil be involved? (NGO, family/whanau or DHB)
.
Recovery Plan (V10 May 2021)
Page 1 of 2
Things I can do to stay wel
Things that may make me unwell
My early warning signs
.
1982
When things are breaking down (crisis plan)
Act
Information
Copy Given To Client: Yes / No
Date
Offical
the
under
Released
Recovery Plan (V10 May 2021)
Page 2 of 2
Document Outline
