Uploaded by tyleshaspurcell

Intake Treatment & Family Plan

advertisement
Agnes Centers for Domestic Solutions
455 South 48 Street suite 105
Tempe, Arizona 85281
Phone 602-430-9685
Fax 602-581-3245
Counseling Intake, Family Assessment and Treatment Plan (revised 05/29/18)
Client
Case #
Counselor
Email
Case Mgr. /Probation Officer
Email
Reason for referral
Date Tx Plan Constructed
Family & personal relationships
Leisure/recreational activities
Problems, issues & areas of
concern
Client & family parenting
issues/parenting style
Social history (reside with, hx
family mental illness
Relationship (romantic) history
(level of seriousness, length,
problems, intimacy issues etc.
Medical history (allergies, special
diet, present & past medications)
Developmental delays and/or
traumatic experiences i.e. physical,
sexual, verbal or emotional abuse
Previous Tx, counseling,
hospitalization for behavioral health
Suicidal thoughts and/or attempts
Substance use/abuse history
Coping skills for anger & stress
Violence history (if any)
Page 1 of 2
Client: ___________________________________
Date: _________________
How does client feel counseling
can help
Additional information/comments
Assessment & Summary
Counseling Treatment Plan
To be completed by counselor only
“Treatment Goals” to improve client
& family* adaptive functioning
Referrals or community support
referrals
Review by (Date) (minimum 6
months out)
Signature (with credentials)
Date
Client Signature
Date
Page 2 of 2
Client: ___________________________________
Date: _________________
Download