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First Name

Last Name

Email Address

Nominated Carer/ Supporter Involvement: I have a nominated carer/ supporter person and I want them involved in my care plan.

YesNoNot applicable

Who is my first support network person if I am in crisis?

Who is my second supporter network person if I am in a crisis?

Which therapy program are you attending?

ACTADHDBuilding Strength & ResilienceCreative TherapiesArt TherapyDBTDual DiagnosisPsychological InjurySuccessful SleepWomen's GroupAddictive Disorders/ Dual DiagnosisCBTDealing with DistressEmotional Eating / Mood & FoodMood & AnxietySchemaTrauma-Focused CBTAddictions IntensiveAnxiety / Depression IntensiveSafe Trauma RecoveryCBTIn Recovery (Addictive Disorders)Building Resilience

What would you like us to know about you and what you want to achieve. your answers help to form your care plan for this program.

Strength 1: This is my strength and how I use it to manage my mental health *

Strength 2; This is my strength and how I use it to manage my mental health *

Strength 3: This is my strength and how I use it to manage my mental health *

Maintaining my safety (Crisis management)- What healthy coping strategies do I currently use to maintain my safety? *

Identify 3 Treatment Goals. 

For each goal, identify what you want to achieve from attendance & treatment. At the end of the program you will review how you met the goals.

In your first session, you will be asked to further work on these goals - identifying steps and actions that will help you to achieve them.

Treatment Goal 1 *

Treatment Goal 2 *

Treatment Goal 3 *

Declaration- Please select from the options below

I have been given the opportunity to actively participate in the development of this care plan. I am aware that this plan will be reviewed by my treating team and any changes will be discussed with me prior to implementation.Both myself and nominated carer / supporter have been provided with the opportunity to actively participate in the development and implementation of this care plan. We are aware that the plan will be reviewed by my treating team and any changes will be discussed with us prior to implementation.

Please sign here *

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I would like to talk about my responses and some coping strategies with a team member

YesNoI'm not sure

 

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