Healthcare PSR ISP Form

Healthcare PSR ISP Form

Patient Information

Date of Birth:    Gender:    Preferred Pronouns:

Primary Phone:    Secondary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance & Coverage

Policy Number:    Group Number:    Subscriber Name:

Program / Provider Information

Primary Clinician / Case Manager:    Contact Phone:

Assessment Summary & Functional Status

Brief clinical summary of current presentation, functional impairments, strengths, and immediate needs:

Strengths, Needs, Preferences

Goals, Objectives, and Interventions

List measurable goals and the specific objectives and services that will be provided to achieve each goal. Each goal includes an assigned responsible staff member, frequency, start date, and target completion date.

Responsible Staff:    Frequency:    Start Date:    Target Date:

Responsible Staff:    Frequency:    Start Date:    Target Date:

Planned Services / Interventions

Select planned PSR services and specify primary provider, frequency, and setting. These services are intended to support the objectives stated above.

Psychosocial Rehabilitation (PSR) — Provider: Frequency:

Skills Training — Provider: Frequency:

Community Support Services — Provider: Frequency:

Individual Therapy — Provider: Frequency:

Group Therapy — Provider: Frequency:

Medication Management — Provider: Frequency:

Case Management — Provider: Frequency:

Peer Support — Provider: Frequency:

Other:

Risk, Safety, and Crisis Plan

Consent, Confidentiality, and Authorization

The patient consents to receive the psychosocial rehabilitation services and other interventions described in this Individualized Service Plan. Services will be delivered consistent with professional standards. The patient understands the potential benefits and known risks of the planned services, including that outcomes cannot be guaranteed and that participation is voluntary.

By signing below, the patient authorizes the program to share relevant health information with other providers and entities for purposes of treatment, care coordination, and payment as necessary to implement this ISP. This authorization excludes disclosure of psychotherapy notes unless expressly indicated. The patient understands the right to revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

The patient has the right to withdraw from services at any time and to participate in the development and review of the ISP. Complaints or grievances regarding care may be submitted to program administration; such submissions will not affect access to services.

I consent to the services and interventions described in this plan.

I authorize sharing of necessary clinical information for treatment and care coordination.

In an emergency, I authorize program staff to seek and permit emergency treatment as needed.

HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the program's notice of privacy practices describing how my protected health information may be used and disclosed, my privacy rights, and the program's legal duties regarding my information.

I acknowledge receipt of the privacy practices notice.

Additional Authorizations / Notes

Sign Now