HTML Preview Outpatient Mental Health Treatment Plan Example page number 1.
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P.O. Box 7338 • Madison, WI 53707-7338
45 Nob Hill Road • Madison, WI 53713-3959
Voice/TDD: (608) 276-4000 • (800) 279-4000
Fax: (608) 661-6706 • Web site: www.weatrust.com
Outpatient Mental Health Treatment Plan
Please complete this entire form and fax
to the attention of Administrative Assistant, Behavioral Health, at (608) 661-6706
Clinic: Tax ID:
Clinician Name, Credentials: Clinic Phone: Fax No.:
Address: Patient Name:
City: Subscriber ID:
State: Zip: Patient DOB:
First date of service: _________________
Authorization requested from date: _________________ Anticipated closure date:
DSM IV Diagnosis—Axis I through V:
Axis I:
Code(s):
Axis II:
Code(s):
Axis III:
Axis IV (specify):
Axis V: Current GAF:
Highest GAF past year:
Current Psychiatric Status
(mark where applicable):
Initial date: Current date:
Symptoms/Problems Mild Moderate Severe Mild Moderate Severe
Depressed mood
Obsessions/compulsions
Anxiety
Impulsiveness
Somatic complaints
Poor judgment
Sexual issues
Impaired concentration
Appetite disturbance
Irritability
Hyperactivity
Sleep disturbance
Delusions
Paranoia
Panic attacks
Hallucinations
Phobias
Impaired memory
Alcohol abuse
Opiate abuse
Prescription medicine abuse
Polysubstance abuse