Please complete the form below
    1. Carer details and/or emergency contact(s) Name or current GP or other HMA Provider Client Number PRESENTING ISSUES: What are the client's current mental health issues? CLIENT HISTORY: Record relevant biological, psychological, and social history including any family history of mental disorders any relevant substance abuse or physical health problems. MEDICATIONS: Attach information if required. ALLERGIES ANY OTHER RELEVANT INFORMATION RESULTS OF MENTAL STATE EXAMINATION: Record after the client has been examined. RISKS AND CO-MORBIDITIES: Note any associated risks and co-morbidities including risks of self-harm and/or harm to others. OUTCOME TOOL USE AND RESULTS DIAGNOSIS TREATMENT GOALS: Record the mental health goals agreed to by the client and GP or HMA Provider. Mention any action(s) the client will need to take. TREATMENT: Treatments, actions, and support services to achieve client goals. REFERRALS: Referrals to be provided by GP or HMA Provider as required. CRISIS / RELAPSE: If required, note the arrangements for crisis intervention and/or relapse prevention. APPROPRIATE PSYCHO-EDUCATION PROVIDED Psycho-social educationYesNo PLAN ADDED TO CLIENT'S RECORDS Client's recordsYesNo COPY (OR PARTS) OF THE PLAN OFFERED TO OTHER PROVIDERS. Plan offered to other providersYesNo COMPLETING THE PLAN: On completion of the plan, the HMA Provider is to record that he/she has discussed with the patient The assessmentAll aspects of the plan and the agreed date for reviewOffered a copy of the plan to the client and / or their carer (if agreed by client). DATE PLAN COMPLETED REVIEW DATE: Initial review 4 weeks to 6 months after completion of the plan. REVIEW COMMENTS: Progress on actions and tasks. Review Comments OUTCOME TOOL & RESULTS ON REVIEW Outcome tool & results on review By submitting this form, the provider acknowledges all information provided was at the consent of the client (family) and caregiver & intended solely for treatment purposes.

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