Recovery Planning Worksheet and Template

Today I am going to be asking you a lot of questions about what things in your life are going well, and
what things you might like to change. Some of the questions might be things like: Who are the most
important people in your life? What is the thing in your life you are most proud of? And, what are your
dreams for the future? We think that this information can be a very important part of your recovery and
treatment. It will be helpful to us as we work together to develop a recovery plan that fits with your
unique goals and preferences.

Hopes and Dreams

1. What are your hopes and dreams for the future? What are some of the most important things you
want to have in your life?

2. If you could change anything in your life right now what would it be?

On a scale of 1-5, how hopeful do you feel about the future? (Circle a #)
1 2 3 4 5
Little or No Very Hopeful
Hope

Important persons in life and recovery

Please help me make a list of all of the people that are important to you or can help you in recovery. In
addition to clinicians or other providers, think about including supportive people like friends, family,
employers, or clergy members. These people may play some part in helping you to carry out your
recovery plan and action steps.
Name Relationship to you How has s/he been supportive? Contact OK?
Complementary Plans and Documents

Do you have an Advance Directive? ___ Y ___N

Do you have a WRAP Plan or other wellness plan? ___Y ___N

Note: Persons with advance directives and/or wellness plans should be encouraged to share those with
the team as means of informing development of the recovery plan. Persons without advance directives
or wellness plans should be educated about these tools and referred for support if interested.

Strengths and Interests

To help you meet your goals we need to think about what strengths you have. Sometimes people have
a hard time remembering their strengths. The following statements may help you get ideas.
 My best qualities as a person are:
 I am most proud of:
 People like that I am (people say they like my):
 The times I am most at peace are when:
 I notice my problems the least when I am:
 The things that help me to make it through the day when I am down are:

Could you tell me about some of your interests or skills? When you answer the question think about
things you:
 Enjoy doing at home or in the community?
 Are interested in or would like to learn more about?
 Like to show other people how to do?
 Used to feel good about before you began to have mental health difficulties
 Care a lot about (like kids or friends or animals)?
Recovery Areas
Now let’s think about different parts of your life, see how you feel, and decide what you would like to
change.

1. WHERE YOU LIVE (HOUSING/NEIGHBORHOOD)

What is your living situation (house, apartment)? Do you live alone, with roommates? How do you feel
about your house/apartment, the neighborhood?

If you want to make changes, what are they? What kind of living situation would you like to be in (if
different from where you are now)?

What are the barriers keeping you from being in the living situation you want to be in? What
kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

2. MONEY/FINANCES
What are your sources of income? What do you usually spend your money on? Do you have enough
money to do the things you would like to do? Are you stressed about money? How do you manage your
money? Do you have a budget?
If you want to make changes, what are they? In terms of money, what would your ideal situation be (if
different from what it is now)?

What are the barriers keeping you from being in the financial situation you want to be in? What
kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

3. WORK
Are you working right now? If so, where? Are you happy with this job? Have you worked in the past?
Are you interested in getting a new or different job now?

If you want to make changes, what are they? What kind of work situation would you like to be in (if
different from where you are now)? What would be your ideal job?
Are you interested in getting a new or different job now?

What are the barriers keeping you from being in the work situation you want to be in (e.g.
transportation, skills training, job availability)? What kind of help would you like?
Consumer Preference Staff Suggestion Decision
1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

4. RELATIONSHIPS
Who are the most important people in your life right now? Are there people you can turn to when things
get difficult? How are your friendships going? How are your family relationships going? Do you have (or
hope to have) a romantic or sexual relationship-how is this going? Are there people that depend on you
(children, elderly relatives)? Who are the people you turn to in times of difficulty?

If you want to make changes, what are they? Would you like to make new relationships or
improve your current relationships?

What are the barriers to forming or improving relationships (e.g. I am shy, I haven’t talked with
my family for years, I don’t know how to meet people)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:
5. EDUCATION/TRAINING
Are you satisfied with your education? Do you feel you have the training you need to do the kind of
work you want to do? Are there things you would just like to learn more about?

If you want to make changes, what are they? What are your goals for education/learning?

What are the barriers keeping you from getting the education/training you want (e.g.
transportation, money for courses)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

6. HEALTH
Are you getting enough rest and exercise? Are you getting enough healthy food to eat? If you smoke
are you interested in trying to quit? Do you have any specific medical problems or concerns about your
health?

If you want to make changes, what are they? What are your goals for staying healthy?
What are the barriers keeping you from being as healthy as possible (e.g. can’t get to doctor,
difficulty quitting smoking)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

7. DAILY LIVING AND ROUTINE

How do you spend your time? What does a “typical” day look like? Is this satisfying/enjoyable for you?
Are there places in the community where you feel comfortable and safe? How do you get to
activities/appointments?

If you want to make changes, what are they? What would your ideal day look like? How/where, with
whom would you like to be spending your time? What kind of things do you like to do that you aren’t
doing now?

What are the barriers keeping you from spending your time the way you would want (e.g. get
nervous around people, don’t know where to go or find resources, transportation)? What kind of
help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus
Staff comments:

8. SPIRITUALITY
How important is faith/spirituality in your life? What are some of your spiritual practices? How satisfied
are you with your opportunities to participate in your spiritual practice or attend the congregation of your
choice right now? Do you belong to a spiritual community, would you like to?

If you want to make changes, what are they? What are your spiritual goals?

What are the barriers keeping you from meeting your spiritual goals (e.g. transportation to
services, barriers to practicing my spiritual practices)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

9. MENTAL HEALTH/SYMPTOMS
How much are your psychiatric symptoms interfering with your life? Are they getting in the way of the
things you’d like to do? How much are your medications helping you? Are you being bothered by
medication difficulties or side effects? How do you cope with your symptoms? What do you do to stay
well?
If you want to make changes, what are they? What are your goals for maintaining your mental health?

What are the barriers keeping you from being as psychiatrically healthy as possible (e.g. don’t
like the side effects of the medications)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

10. DRUGS AND ALCOHOL

Do drugs and/or alcohol influence your life right now? If so, how?

If you want to make changes, what are they? What are your goals for reducing or eliminating your use
of drugs and alcohol and/or for decreasing the harmful effect they have on your life?

What are the barriers to reaching these goals? (e.g. all my friends use, there are a lot of drugs
in my building)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus
Staff comments:

11. SAFETY
Do you ever feel that you are at risk to hurt yourself or someone else? What do you do to
control that risk? What makes you feel more safe? What is the most important safety concern
in your life? Are you concerned for your own safety for any reason, e.g., do you feel personally
safe in your neighborhood?

If you want to make changes, what are they? What are your goals for being safe?

What are the barriers to staying safe (e.g. there is a lot of crime in my neighborhood, when I
drink I tend to lose my temper)? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

12. LEGAL ISSUES

What, if any, legal issues are you dealing with right now? (e.g., court appearance, probation
requirements, etc.)
If you want to make changes, what are they? What are your goals for reducing or eliminating legal
problems?

What are the barriers to reducing or eliminating your legal problems? What kind of help would
you like?

Consumer Preference Staff Suggestion Decision

1. __ Work on Now 1. __ Work on Now 1. __ Work on Now
2. __ Work on Later 2. __ Work on Later 2. __ Work on Later
3. __ Not a focus 3. __ Not a focus 3. __ Not a focus

Staff comments:

13. OTHER ISSUES

Are there other things that are important in your recovery that we have not covered so far? Are
there any other issues or areas in your life where you’d like to make changes?

If you want to make changes, what are they? What are your goals in this area?

What are the barriers for reaching this goal? What kind of help would you like?

Consumer Preference Staff Suggestion Decision

4. __ Work on Now 4. __ Work on Now 4. __ Work on Now
5. __ Work on Later 5. __ Work on Later 5. __ Work on Later
6. __ Not a focus 6. __ Not a focus 6. __ Not a focus

Staff comments:
Master Recovery Plan Name:______________
Chart: ______________
Team: ______________
Date: ______________
My Hopes and Dreams are:

On a scale of 1 - 5, how hopeful do you feel about the future:

(1 = Little or no hope, 5 = Very hopeful)?

My Personal Strengths are:

My Interests include:

If I could change something in my life right now, I would change...

Staff Comments:

People Important in My Life and Recovery

Name Relationship to you How has s/he been supportive? Contact OK?
Master Recovery Plan Name:______________
Recovery Focus List Chart: ______________
Team: ______________
Date: ______________

Recovery Area Identified Goal Work on Date Goal

Now/Later/Not a Established
Focus

Housing/Neighborhood:

Money/Finances

Work

Relationships

Education and Training

Health

Daily Living & Routine

Spirituality

Mental Health/Symptoms

Drugs and Alcohol

Safety

Legal Issues

Other

Note: For each “Work on Now” area identified above, complete Action Plan as per below.
Master Recovery Plan Name:______________
Action Plan (one for each “Work on Now area) Chart: ______________
Team: ______________
Date: ______________

FOCUS AREA: Date Established:

Recovery Goal:

Objectives (Short Term Change Desired, Note Target Date for Achievement):

1.

2.

ACTION PLAN & INTERVENTIONS

Action Steps Person in Recovery will take:

Action Step:
Frequency:
Duration:

Services to be Provided by Behavioral Health Agency:

Service Type:
Provider:
Frequency:
Duration:
Intended Impact/Purpose:

Services/Assistance to be provided by Other Providers or Service Agencies

Assistance/Service:
Provider:
Frequency:
Duration:
Intended Impact/Purpose:

Services/Assistance to be provided by Natural Supporters

Type of Support:
Supporter:
Frequency:
Duration:
Intended Impact/Purpose:
Master Recovery Plan Name:____________

Diagnosis, Participation and Signatures Chart: ____________

Team: ____________
Date: ____________

PSYCHIATRIC DIAGNOSIS (DSM-IV)

DSM IV
Axis: Code: Diagnosis:

RECOMMENDED LEVEL OF CARE

Level of Care: Provider:

SIGNATURES
Printed Name: Signature:
Consumer ___________________________ Date:
This plan has been reviewed by me and I have been offered a copy.

Psychiatrist: ___________________________ Date:

Case Manager ___________________________ Date:

Nurse: ___________________________ Date:

Supervisor: ___________________________ Date:

Other Provider ___________________________ Date:

Clinician ___________________________ Date:

Peer Provider: ___________________________ Date:

Family: ___________________________ Date:

Other Supporter: ___________________________ Date:

Other Supporter: ___________________________ Date: