SAMHSA's National Mental Health Information Center

This Web site is a component of the SAMHSA Health Information Network

About the Toolkits

Illness Management and Recovery

Assertive Community Treatment

Family Psychoeducation

Supported Employment

Co-occuring Disorders: Integrated Dual Diagnosis Treatment

Feedback Form

Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Illness Management and Recovery Fidelity Scale

APPENDIX

Name: ________________________ ID# _____________ Date: ___________

Name of significant other(s) involved in session: _________________________

Problem or goal specified by the treatment plan that is the focus of the person’s treatment: ____________________

_______________________________________________________________

Personal goal that was set in this session or followed up in this session: ___________________________________

_______________________________________________________________

TREATMENT/INTERVENTIONS PROVIDED:

Motivational interventions (check all that apply):

_____ connect info and skills with personal goals

_____ promote hope & positive expectations

_____ explore pros and cons of change

_____ re-frame experiences in positive light

Educational interventions (check the topic(s) that were covered):

_____ Recovery strategies

_____ Practical Facts about Mental Illness

_____ Stress-Vulnerability

_____ Social Support

_____ Using Medication

_____ Reducing relapses

_____ Coping with Stress

_____ Coping w/ Symptoms & Problems

_____ Mental Health system

Cognitive-behavioral interventions (check all that apply):

_____ reinforcement

_____ shaping

_____ modeling

_____ role playing

_____ cognitive restructuring

_____ relaxation training

Specific evidence-based skill taught (identify which one(s))

coping skill for dealing with symptoms: _________________________________________________________

relapse prevention skill: _______________________________________________________________

behavioral tailoring for medication: ____________________________________________________________

Homework that was agreed upon: _____________________________________________________________

OUTCOME (person’s response to info, strategies & skills provided in the session)

Person’s perspective: ______________________________________________________________

Practitioner’s perspective: ______________________________________________________________

PLAN for next session: ______________________________________________________________

Person’s signature: ______________ Practitioner’s signature ______________

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