Suicide Assessment and Prevention

School of Professional Counseling Treatment Plan Template

Intern Name: Date:

Client Name: Use name if one is given in case. Make up last name or full name if none is given in case. Not just initials for this treatment plan.

Ethical check for crises:  If your client is currently experiencing a crisis issue(s) (e.g., suicidal ideation, homicidal ideation, and/or domestic or partner violence), one or more of the presenting problems (below) and problem/goals (listed in the chart) should address the specific crisis issue(s) with a remediation plan. NOTE: Create a safety plan and attach as separate document.

PRESENTING PROBLEMS: Brief statement of treatment issues; if there are more than one, discuss each one briefly…Note that I am requesting at least two problem statements. See page 2 of this document.

DIAGNOSIS & SPECIFIER(s):

1. DSM-5: Name of diagnosis

2. ICD 10 #s: (F-Code only)

DIFFERENTIAL DIAGNOSIS (es):

TREATMENT PROCEDURES

1. Mode of therapy: Individual

2. Sessions per week expected:

3. Total number of sessions expected (including past sessions):

Note about how to write goals: Consider utilizing the SMART Goals process when working with clients in a clinical counseling setting. A quick description is given below (also see the following handouts on the Blackboard course page ( SMART Goals and Writing SMART Goals):

· Specific - Well defined, clear approach to helping clients understand their own needs as it relates to their mental, emotional, social, behavioral and relational health.

· Measurable - Know if the goal is obtainable for your client, and how far away completion is. Also, determine when you have achieved your goal with your client/s.

· Agreed Upon - There should be a mutual and collaborative process where both the counselor and client have an agreement of the achievement of a goal.

· Realistic - Within the availability of resources, knowledge and time, all goals should be realistic in how they apply the client's life and circumstances

· Time-Based - There should be sufficient time in which the client can achieve the specific therapeutic goal. Counselors should be mindful of establishing goals with clients that could be too time consuming, and equally, one should avoid setting goals where the client does not have enough time to accomplish the goal.

Delete the highlighted areas BEFORE submitting.

List at least 2 problem statements, each problem 2 goals; each goal, 2-3 objectives/short-term goals with matching interventions. If referring to Treatment Planner textbook: Please include page numbers, and at end of document include APA reference.

Problem 1:

Goal 1:

Date	Objectives	Projected Achievement Date	Clinical Intervention

Goal 2:

Date	Objectives	Projected Achievement Date	Clinical Intervention

Problem 2:

Goal 1:

Date	Objectives	Projected Achievement Date	Clinical Intervention

Goal 2:

Date	Objectives	Projected Achievement Date	Clinical Intervention

_________________________________________ __________________________

Client Signature Date

_________________________________________ __________________________

Intern Signature Date

Create Signature lines for both you and client, with signature date lines. Use font change to look like two different signature. Then remove the blue instructions. Reminder: Please attach a separate safety plan for client. If you have not created one before, look for example in resources provided on Bb on contact instructor.