Briefly state client’s relevant demographics. Summarize client’s presenting issue here, including subjective and objective information obtained from intake. State client’s current level of suicidal (SI) and homicidal ideation (HI) and reported symptoms of psychosis.
Diagnosis Do the best you can with this section. The intent is not to be perfect, but to practice! The diagnosis can be broad and does not have to be coded. If you have already taken the diagnosis course and want to be more specific, feel free to practice that here.
Assessments Any assessments that may be helpful in treatment (1-2)
Treatment Clinicians
Location
Number of People
Timing
Short-term Goals
What the client will accomplish 1. All goals, short-term and long-term must be OBJECTIVE and MEASURABLE.
2.
3.
Long-term Goals 1.
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3.
Proposed Interventions
How the clinician will help the client accomplish goals 1. State what type of interventions you recommend for the client here. This can be recommendations for the number of counseling sessions attended per week/month, the type of counseling recommended to the client, referrals to outside resources, psychiatric evaluation for medication, and specific treatments recommended (e.g., Cognitive Behavioral Therapy, exposure therapy for anxiety disorders, etc.)
2.
3.
Medications Should a referral be considered? Do not attempt to say what kinds of medications as this is beyond our scope.
Adjunct Services
Prognosis
Sample Solution