treatment plan paper
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!CLIENT HAS TO BE FROM BIBLE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Case Presentation and Treatment/Counseling Planning
I. Identifying Information
(First initial, age, gender, culture/ethnicity, religion, level of education, work setting etc.)
II. Clinical Impression including Mental Status Assessment
III. (Description of the client’s appearance, behavior, speech etc. if you are working with a family then you will need to do for each member as well as for the family unit (where they sit, how they are interacting as they walk in etc.)
IV. Presenting Problems including Chief Complaints (symptoms)
(The presenting problem may be, “My husband died.” The chief complaints may be, “I can’t sleep, and I have lost the will to live.” This area is identified as the client sees the problems and relates his/her symptoms or complaints. Also includes the client’s thoughts as to why the problems or symptoms are present at this time. Recent cries? )
V. History-original family, social, mental health and medical history
Description of childhood, adolescence, adulthood including marriage, children, other relationships etc. History of family and any medical and psychological problems. Chronic illnesses or complaints, operations, hospitalizations, medication and dosage, over the counter medications, herbal supplements, caffeine, alcohol, illicit drug intake? Previous and current interaction with medical and mental health personnel. Include alternative medical treatment( chiropractor, massage, acupuncture etc.)
VI. Treatment Planning
VII. Counseling Planning
Client’s main problem:
Counseling goal:
Total number of session: 6
1. Session #1
Area I intend to work:
Intervention:
Homework:
2. Session#2
Area I intend to work:
Intervention:
Homework:
3. Session#3
Area I intend to work:
Intervention:
Homework:
4. Session#4
Area I intend to work:
Intervention:
Homework:
5. Session#5
Area I intend to work:
Intervention:
Homework:
6. Session #6
Area I intend to work:
Intervention:
