Regulation 5(1)
Gall y cynllun hwn cael ei gwblhau yn y Gymraeg neu yn y Saesneg, neu yn rhannol yn y Gymraeg ac yn rhannol yn y Saesneg
This plan may be completed in the Welsh or the English language, or partly in Welsh and partly in English
This care and treatment plan has been prepared under section 18 of the Mental Health (Wales) Measure 2010, and in accordance with the requirements of the Mental Health (Care Coordination and Care and Treatment Planning) (Wales) Regulations 2011.
This is the care and treatment plan of [Name of relevant patient] who lives at [Full usual address of relevant patient].
The care coordinator who has prepared this care and treatment plan is [Name of care coordinator] who can be contacted at [Telephone number, postal address and, where appropriate, email address of care coordinator]. The care coordinator has been appointed by, and is acting on behalf of, [Name of Local Health Board or Local Authority that appointed the care coordinator].
This plan was made on [Date the plan was made] and is to be reviewed no later than [Date by which the plan must be reviewed]. However, [Name of relevant patient], his or her carer(s) or adult placement carer(s) may request a review of this care plan at any time.
This part of the care and treatment plan records the outcomes which the provision of mental health services are designed to achieve, details of those services that are to be provided, and the actions that are to be taken with a view to achieving those outcomes.
[The planned outcome(s) included in the following part of the plan must relate to one or more of the areas listed, and include an explanation of how each outcome relates to each area. Outcomes also may be achieved in other areas, and are to take into account any risks identified in relation to the relevant patient.
This part of the plan also sets out details of the services that are to be provided, or actions taken, to achieve the planned outcomes, including when, and by whom those services are to be provided or actions taken.
[Outcomes to be achieved must be agreed in relation to at least one of the following areas:
a)accommodation
b)education and training
c)finance and money
d)medical and other forms of treatment, including psychological interventions
e)parenting or caring relationships
f)personal care and physical well-being
g)social, cultural or spiritual
h)work and occupation.
Outcomes to be achieved may also be agreed in relation to other areas]
Outcome to be achieved
What services are to be provided, or actions taken
When
Who by
The following thoughts, feelings or behaviours may indicate that [Name of relevant patient] is becoming more unwell and may require extra help from the care team (these are sometimes called relapse signatures):
If [Name of relevant patient] feels that his or her mental health is deteriorating to the point where he or she requires extra help or support, the following actions ought to be taken (this is sometimes known as a crisis plan and must include details of the services to be contacted):
Any language or communication requirements or wishes which [Name of relevant patient] has (including in relation to the use of the Welsh language) ought to be recorded here:
The views of [Name of relevant patient] on this care and treatment plan, the mental health services that are to be provided, and any future arrangements that ought to be considered, are:
[Record any views that the relevant patient wishes to be included (including past and present wishes and feelings about the matters covered by the plan), and include any statements about any future arrangements which may apply. If the patient does not have any views or statements on these matters, or the patient’s views cannot be ascertained, this ought to be recorded also.]
This care and treatment plan has
* been agreed with [Name of relevant patient] and is recorded in accordance with section 18(2) of the Mental Health (Wales) Measure 2010
* not been agreed with [Name of relevant patient] but the outcomes have been determined by the mental health service provider(s), and are recorded in accordance with section 18(6) of the Mental Health (Wales) Measure 2010
[* delete as applicable (one, but not more than one, statement must apply)]
So far as it is reasonably practicable to do so, the following mental health service provider(s) must ensure that the mental health services set out in this care and treatment plan are provided: [Enter the name of the Local Health Board and/or the Local Authority who are responsible for providing secondary mental health services to the relevant patient]
Signed [The relevant patient may sign the care and treatment plan, if they wish] Relevant patient
Signed [The care coordinator must sign this care and treatment plan] Care coordinator
Date [Enter the date the care and treatment plan is made]