DO A CLIENT MAP







Diagnosis



Objectives of Treatment







Assessments (for example, neurological, or personality tests)







Clinician characteristics



Location of treatment



Intervention to be used



Emphasis of treatment (for example, level of directiveness; level of supportiveness; cognitive, behavioral, or affective emphasis



Numbers (that is, the number of people in treatment: individual, family, or group)



Timing (frequency, pacing, duration)







Medications needed



Adjunct services



Prognosis







Seligman, L. (2005). Principles of psychopathology diagnosis and treatment: Selecting effective treatments. Hoboken, NJ: John Wiley & Sons, Inc..







____________________________________________________________







Treatment Therapeutic Modalities:







Psychoanalytic



Jungian



Adlerian



Existential



Person - Centered



Gestalt



Cognitive - Behavioral



Reality



Solution - Focused Brief Therapy



Narrative



Family



Eastern



Body - Centered Counseling and Psychotherapy



Feminist Theory



Multicultural Considerations



Capuzzi, D., & Gross, D. R. (2003).Theories of psychotherapy, counseling and psychotherapy: Theories and interventions, (3rd Ed.). Boston, MA: Pearson.



Ethical Standards



Herlihy, B., & Corey, G. (2006). Aca ethical standards casebook, (6th Ed.). Alexandria, VA: American Counseling Association.

The Holy Spiritual Order of Shams
Treatment Plan
Program:_________________________ Date of Plan_______________ Review Date_______________
Name:___________________________ Chart #:____________________________________________
Diagnosis
(DSMIV Code)

Axis I__________________________________________________________Code:________________
____________________________________________________________________________________
Axis II _________________________________________________________ Code:_______________
Axis III_____________________________________________________________________________
Axis IV_____________________________________________________________________________
Axis V GAF Score (Current):____________________________________________________________
____________________________________________________________________________________
Risk Assessment
Suicidality: Current Ideation Yes ( ) Past Attempt: Yes ( ) X – Times ( ) Date(s)___________________
Homicidality: Current Ideation Yes ( ) Past Attempt Yes ( ) X – Times ( ) Date(s)__________________
Drug Abuse: Current Abuse Yes ( ) What?_________________________________________________
Other: ______________________________________________________________________________
Comment: ___________________________________________________________________________
____________________________________________________________________________________
Mental Status
Date of most recent Mental Status:_______________________________________________________
Is there any new symptoms? ( )yes ( )No If yes describe_________________________________________________________________________________________________________________________________________________________________
Change / relief in old symptoms? Yes ( ) No ( ) Describe________________________________________________________________________________________________________________________________________________________________
Functional Assessment
Level of Impairment
(check one for each category)
None Mild Moderate Severe Extreme
Health 1 2 3 4 5
Social / Interpersonal 1 2 3 4 5
Educational / Vocational 1 2 3 4 5
Money Management 1 2 3 4 5
Leisure (hobbies, Interest, etc.) 1 2 3 4 5
Date of last physical exam__________________ Date of last psychosocial evaluation_______________
Date of last tobacco use assessment___________________ Date of last Vocational evaluation_______
Describe change in patient’s condition (health, living, work, family, etc..)____________________________________________________________________________________________________________________________________________________________________

Summary Presenting Problem
(Identity Stressors, Symptoms, Duration)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Strengths
Good Physical Health ( ) Financial Support ( ) Motivation for Treatment ( )
No Psychiatric hospitalization in past year ( ) Significant Education ( ) Insight into illness ( )
Adequate support system ( ) Significant work history ( )
Adequate housing system ( ) Social / Interpersonal Skills ( )
____________________________________________________________________________________
Guidelines
Problems: Describe areas of impairment in behavioral terms.
Goals: Formulate changes to be achieved on behaviors, functioning, systems.
Motives: Specify in behavior terms changes in skills, symptoms, and emotions that lead to goals
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Problem 1:
Goal:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Objective(s) Patient Will ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Will: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Modality of Treatment:
Individual ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Couple ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Family ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Group ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Medication ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Types and dosage / day: __________________________________________________________
Reason:_____________________________________________________________________________

Problem 2:
Goal:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Objective(s) Patient Will ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Will: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Modality of Treatment:
Individual ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Couple ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Family ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Group ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Medication ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Types and dosage / day: __________________________________________________________
Reason:_____________________________________________________________________________

Problem 3:
Goal:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Objective(s) Patient Will ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Will: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Modality of Treatment:
Individual ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Couple ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Family ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Group ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Medication ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Types and dosage / day: __________________________________________________________
Reason:_____________________________________________________________________________

Problem 4:
Goal:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Objective(s) Patient Will ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Will: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Modality of Treatment:
Individual ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Couple ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Family ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Group ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Reason:_____________________________________________________________________________
Medication ( ) 1 week ( ) Bi-weekly ( ) Monthly ( ) Other ( ) _______ Duration______ Staff_____
Types and dosage / day: __________________________________________________________
Reason:_____________________________________________________________________________
____________________________________________________________________________________
Other Services
A) Case Management
No ( )
Yes ( ) Explain:________________________________________________________________
• Linkage to other program(s) / services:
Issues:__________________________________________________________________
Goal:___________________________________________________________________
Objectives:______________________________________________________________
Intervention:_____________________________________________________________
• Advocacy:
Issues:__________________________________________________________________
Goal:___________________________________________________________________
Objectives:______________________________________________________________
Intervention:_____________________________________________________________
• Vocational Services:
Issues:__________________________________________________________________
Goal:___________________________________________________________________
Objectives:______________________________________________________________
Intervention:_____________________________________________________________
• Chemical Dependency Program:
Issues:__________________________________________________________________
Goal:___________________________________________________________________
Objectives:______________________________________________________________
Intervention:_____________________________________________________________
• Smoking Cessation Program:
Issues:__________________________________________________________________
Goal:___________________________________________________________________
Objectives:______________________________________________________________
Intervention:_____________________________________________________________
B) Additional Services:
Issues:__________________________________________________________________
Goal:___________________________________________________________________
Objectives:______________________________________________________________
Intervention:_____________________________________________________________
________________________________________________________________________________
Plan of Discharge
A) Client / Parent / Guardian: (Perception of what client expects from participation in the program)
What is your expectation, what do you want from this program? Specify verbatim:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B) Staff: Specify changes in behavior, ability to function, symptoms to be achieved before discharge
The client will____________________________________________________________________
________________________________________________________________________________
The client will____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Patient’s Name Signature Date
_______________________ ___________________________________ ____________________
Clinician’s Name Title Signature Date
___________________ ___________ _______________________________ _________________
Supervisor’s Name Title Signature Date
___________________ ___________ _______________________________ _________________
Psychiatrist’s Name Title Signature Date
________________________ ____________ _________________________ __________________