Eliza Treatment Plan case Study

 

Treatment Plan Template

Based on the information collected in week 4, complete the following treatment plan for your client Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember to incorporate the client’s strengths and support system in the treatment plan.

When completing a treatment plan with a client, be sure to include a diagnosis from the DSM V. This would include the diagnosis, specifiers, and code from the DSM. The ICD Code should also be included.

Include a minimum of two overall goals, at least two objectives for each goal, and at least one intervention for each objective. If you have more than two overall goals, simply copy and paste the chart below.

 

Client: Eliza

Date: 17th December 2021

Age: 18 years

DOB: January 15th, 2003

 

 

ICD-10 Diagnosis (Code) Adjustment Disorder (309.28) Alcohol Use Disorder (305.00)

DSM Diagnosis (Code and Description) F43.23 F10.10

 

 

Description of the Problem: The patient is experiencing anxiety, stress, and low self-esteem due to her adjustment disorder.
Goal # 1: Reducing the patient’s anxiety symptoms.
Objective(s):	Intervention(s):	Frequency:	Target Date:
1. Stabilizing patient’s mood.	Cognitive Behavioral Therapy Skills Training Referral to Psychotropic Medication and consultation	☐ Weekly ☐ Bi-Weekly ☐ Monthly ☐ Other: _________________ Modality: ☐ Group ☐ Individual ☐ Family	14th January 2022
2. Increasing patient’s skills of coping with anxiety.	Cognitive Behavioral Therapy Relaxation Techniques Training Skills Training Journaling	☐ Weekly ☐ Bi-Weekly ☐ Monthly ☐ Other: ___________________ Modality: ☐ Group ☐ Individual ☐ Family	14th January 2022

 

 

Description of the Problem: The patient has Alcohol Use Disorder which needs to be addressed because she is in a campus that does not allow alcohol.
Goal # 2: Ensuring that the patient abstains from alcohol and any other drugs.
Objective(s):	Intervention(s):	Frequency:	Target Date:
1. Ensuring the patient attends therapy for alcoholism support and prevention.	Substance Use Assessment Attending Meetings Obtaining sponsor	☐ Weekly ☐ Bi-Weekly ☐ Monthly ☐ Other: ____________________ Modality: ☐ Group ☐ Individual ☐ Family	14th January 2022
2. Eliminating and decreasing self-harm behaviors	Cognitive Behavioral Therapy Skills Training Attending Group Therapy	☐ Weekly ☐ Bi-Weekly ☐ Monthly ☐ Other: ____________________ Modality: ☐ Group ☐ Individual ☐ Family	14th January 2022

 

 

 

 

 

 

 

 

References

Poulsen, R., Fisker, J., Hoff, A., Hjorthøj, C., & Eplov, L. F. (2017). Integrated mental health care and vocational rehabilitation to improve return to work rates for people on sick leave because of exhaustion disorder, adjustment disorder, and distress (the Danish IBBIS trial): study protocol for a randomized controlled trial. Trials, 18(1), 1-15.

Campbell, E. J., Lawrence, A. J., & Perry, C. J. (2018). New steps for treating alcohol use disorder. Psychopharmacology, 235(6), 1759-1773.

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