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: _________________