MENTAL HEALTH SERVICES
INITIAL DIAGNOSIS AND TREATMENT PLAN
Client name: _________________________________________ Date: _____________
Plan for: __ Individual therapy __ Couple therapy __ Family therapy
Other participants (name and relationship):
Diagnosis:
AXIS I ____________________________________________________
____________________________________________________
___________________________________________________
AXIS II ___________________________________________________
AXIS III ___________________________________________________
AXIS IV ___________________________________________________
___________________________________________________
AXIS V Intake GAF: ____ Highest past year: _____
Symptoms/justification for diagnosis: _____________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Anticipated treatment frequency: __ Weekly __ Bi-weekly __ Monthly __ Other: ________________
Anticipated duration of treatment: __________________________
Short-term objectives: (target date < 3 months) Target date:
1. _________________________________________________________________________
___________________________________________________________________________ ___________
2. _________________________________________________________________________
___________________________________________________________________________ ___________
3. _________________________________________________________________________
___________________________________________________________________________ ___________
Long-term goals/discharge criteria:
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
Client’s strengths and assets: _________________________________________________________________
_________________________________________________________________________________________
Obstacles to treatment: ______________________________________________________________________
_________________________________________________________________________________________
Developmental considerations/demands of the diagnosis (for child/adolescent):__________________________
_________________________________________________________________________________________
Other treatments/services client is receiving: _____________________________________________________
Additional services recommended: _____________________________________________________________
I understand and agree to the goals and services outlined in this treatment plan and I have been given the opportunity to give my input into developing this plan. We have discussed potential risks and benefits of the recommended treatments, as well as treatment alternatives.
Client signature _____________________________ Signature of parent/guardian _______________________
Clinician Signature ________________________________________ Date __________
-----------------------
Planned treatment methods:
__ Cognitive therapy
__ Behavioral therapy
__ Narrative therapy
__ Solution-focused therapy
__ Systemic therapy
__ Supportive psychotherapy
__ Play therapy
__ Skill-building in the area of:
__ Communication
__ Relaxation
__ Social skills
__ Parenting
__ Anger management
__ Trauma counseling
__ Psycho-education
__ Building insight
__ Client empowerment
__ Crisis management
__ Homework/exercises
__ ______________________
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