MENTAL HEALTH SERVICE FOR OLDER PEOPLE
Wellness Plan Front Cover Sheet
Name:
DOB:
Address:
NHI:
NOK details:
EPOA/Welfare Guardian:
GP:
GP Phone:
Date
Diagnosis
Relevant History :
Violence (low/moderate/high)
Known Risk Issues
Suicide
Comment on dates,
DSH
and actual and
Wandering
potential events. See Falls
separate risk
Vulnerability
assessment.
Social isolation
Other
under the Offical Information Act 1982
Psychiatrist
OT
Psychologist
CMHN
S/W
Other
Released
Medications
Wellness Plan
Name:
Date of Plan:
Updated:
Service user participation in Wellness Plan ☐YES ☐ NO If no, reason why:
Appointments discussed ☐YES ☐ NO Medications discussed ☐YES ☐ NO
My triggers:
My early warning signs:
What helps me:
My Crisis Plan:
My supports:
Personal support, friends, whanau
under the Offical Information Act 1982
My Key Worker is:
Phone number: Available hours:
My plan for care of children, pets and household:
Released
My plans for fol ow-up and engagement with other services:
Service name
What they do
Key contact person
Phone number
Wel ness Plan copied to:
☐ WebPAS linked (Compulsory) ☐ Clinical file ☐ GP ☐ Service user ☐ SCR updated
☐ Family/whanau (Please specify) …………………………….. ☐ Other (Please specify)……………………..
Service User consents to copies shared with person(s) ticked above ☐ Yes ☐ No If no, reason why:
Clinician signature and designation: (ensure legibility)
Service user signature
Date:
Date:
Urgent contact numbers
Non-urgent contact numbers
For urgent assistance please contact the
Community Mental Health Services:
police/ambulance/fire brigade : Dial 111
Free phone: 0508 292 467 – ABC TEAM, Option 1.
North Team (Taranaki Base Hospital, New Plymouth) Option 3
Free call or text 1737 any time for support from a trained South Team (Hawera Hospital, Hawera) Option 5
counsellor any time of day or night.
MH Services Older People (Taranaki Base Hospital, New Plymouth)
Option 4
Mental Health ABC (Assessment and Brief Care) Team.
Alcohol and Drug service (Taranaki Base Hospital, New Plymouth) –
Free phone 0508 292 467 - Option 1.
Option 6
Tui Ora Mental Health and Addiction Services- Maratahu St, New
Plymouth – 06 7594 064
Triggers:
Triggers are external events or circumstances that make you feel uncomfortable. They may make you feel stressed or like you
are becoming unwell. Triggers may tempt you to resort to using a substance, or doing something you wish to avoid, to help
yourself feel better. These are normal reactions to stressful events in your life, but if you don’t respond to them and deal with
them in some positive way, they may make you feel even worse or lead to a relapse.
The awareness that this can happen, and development of a plan to deal with triggering events when they come up, will
increase your ability to cope without feeling worse or doing something you don’t want to do.
Some examples of warning signs include:
Anniversary dates of losses or trauma, being over tired, work stress, financial or housing worries, relationship issues, physical
unwellness, being around an abuser, event or someone who reminds you of an abuser.
Early warning signs:
In spite of your best efforts, you may begin to experience early warning signs.
Early Warning Signs are subtle signs of change that indicate you may need to look after yourself better or take some further
action. Warning signs include old behaviours that are related to an addiction or a mental illness. You are probably aware of some
of your warning signs but remember to ask your friends and family as well because they might have noticed some things you
haven’t.
under the Offical Information Act 1982
Some examples of early warning signs include:
Irritability, lack of motivation, beginning of irrational thought patterns, feelings of discouragement, hopelessness, craving
addictive substances, and changes to sleep pattern.
Reviewing your early warning signs regularly can help you become aware of them, in order for you to take action at an early stage
before they worsen.
What helps me: Released
Some examples to support my wel being include:
Make sure you let others around you know what you are
Try to keep to usual patterns of activities
feeling and experiencing
Learn as much as you can about your illness
Practice mindfulness, relaxation and meditation
Visualise your goals
Continue to take prescribed medication
Reward yourself for positive steps
Talk to your GP, keyworker or peer support worker about
Keep a diary or journal
what you are experiencing. Your Health Worker will discuss
Try to exercise for fun and health and keep a healthy diet
with you possible options for closer support. Options may
Use sleep encouraging techniques
include - Medication review, respite, problem solving and
Identify potential stress and attempt to reduce it’s impact
stress management techniques, and increased support from
Seek out supportive family and friends
your Health Worker/s.
C
HIL
Affix Patient Label
D
& ADO
My emergency plans:
L
E
• CAMHS duty worker Monday - Friday, 8am - 4pm: 027 425 4319
S
• ABC (Assessment Brief Care) Weekends or after hours: 0508 292 467 (leave a message)
C
E
...............................................................................................................................................................
N
T
...............................................................................................................................................................
M
E
...............................................................................................................................................................
N
T
My medications:
A
Medication name
What it is for
When to take it
What I need to know
For prescribed dosage details please refer to last prescription copy or clinic letter.
Hikoi
L
H
E
A
L
T
H
S
My follow up plans:
Service name
What they do
Key contact name
Phone
My journey with purpose
E
R
VICE W
under the Offical Information Act 1982
E
L
What I need from these other services:
L
N
E
S
S P
Released
L
CAMHS Staff Use
A
N
WebPAS LInked
Clinical file
Family/whānau
GP
WebPAS SCR Completed
Clinician signature:
(D
R
Date created:
Date/s reviewed:
A
Published: Communications Team. Responsibility: CAMHS. Date Published: November 2018. Last Reviewed: November 2018. Version: 1
F
T)
,
Wha
Key worker:
t invites the problem?
Contact:
t is the problem?
Wha values, school
eg physical, emotional, friends, family
Wha
My goal...
t does the problem not
let me see?
e the problem smaller
t do I need from others
Wha
to mak
under the Offical Information Act 1982
Wha
Released
t can I do to mak
problem smaller?
t do I want from my life?
e the
, values, school
Wha
eg physical, emotional, friends,
family
A&D Wellness Plan
Clinician: _______________
Please Adhere Service Label Here
_______________________
_______________________
Alcohol and Drug Service, Monday- Friday 8am-4pm: 06 753 7838 or 0508 292 4672 Option 6
TDHB Assessment and Brief Care Service: 0508 292 4672 Option 1
Alcohol and Drug Helpline: 0800 787 797
Tui Ora Mental Health & Addiction Service: 06 759 4064
Urgent Assistance: 111
24/7 Counsellor text/call line: 1737
My goals are:
☐ __________________________________________________________________________________
☐ __________________________________________________________________________________
☐ __________________________________________________________________________________
☐ __________________________________________________________________________________
My early warning signs are:
☐ Thoughts of using substance
☐Rejecting help
☐Discontinuing treatment
☐ Impulsive behaviour
☐Irritation with others
☐Feelings of hopelessness
☐ Feelings of dissatisfaction
☐Irregular sleeping habits
☐"I don't care" attitude
☐ Other ____________________________________________________________________________
My triggers are:
☐ Feeling hungry
☐Feeling tired
☐Feeling lonely
☐ Feeling angry
☐Feeling stressed
☐Social situation
☐ Other ____________________________________________________________________________
☐ Other ____________________________________________________________________________
under the Offical Information Act 1982
Things that help me are:
☐ Distraction
☐Going for a walk
☐Talking to someone
☐ Time off work/ responsibilities
☐Deep breathing
☐Getting a medication check
☐ Other ____________________________________________________________________________
Released
When things aren't going well I will:
☐ Call the crisis team
☐Call my A&D counsellor
☐Call an ambulance
☐Supporting Parents, Healthy Children
☐How can my whanau support me? ____________________________________________________
☐Call the alcohol & drug helpline
☐Attend a group meeting
☐Other ___________________________________________________________________________________
Clinician Sign: _________________ Client Sign: ______________________ Date: ________________________
Trial Format. Review date: 28 February 2020
Document Outline
