Assignment 1: Treatment Plan Report
For this assignment, you will review the recording of your first (intake) session with your practice client, and you will develop a 3- to 4-page report that includes a treatment plan that is culturally relevant, ethical, and legally appropriate.
The final product will be a report. Your report should be approximately 3â€’4 pages and will include progress notes for this session (1/2 a page), a treatment plan (a 1/2-page chart), a risk management plan (1/2 a page), a case conceptualization (1/2 a page), and self-reflection (1â€“2 pages).
Part I: Conduct Counseling Session :
- Meet with your practice client over digital media (Zoom, Teams, Doxy, etc.) to conduct and tape the second counseling session. Begin the session where you left off after the intake appointment. Summarize your understanding of the client’s presenting problem(s) (this is your basic case conceptualization) and ask your client to confirm that you understand correctly then ask how things are going since the last meeting. Next, collaborate with your client on the treatment plan (at least two goals with 2-4 objectives for each goal). Be sure to infuse your theoretical orientation in the session. End the session with a summary of the session and set the time for your next session.
Part II: Write a Report:
Follow the details below pertaining to the report’s requirements.
Your 2-4 page report should follow APA 7th ed. guidelines for writing style, particularly chapters 3 (Writing Clearly and Concisely) and 4 (The Mechanics of Style). Clear documentation of services is a very important skill that can result in a client’s services being reimbursed or denied and, therefore, is a client welfare issue. You should have a title page and a header labeled “Session Twoâ€”Treatment Plan, and Your Name “
A. Progress Notes: (approximately 1/2 a page):
Document your session in a progress note using one of the approved formats that you learned about in Module 2 of the class (Subjective, Objective, Assessment, Plan [SOAP], Data, Assessment, Plan [DAP], or Behavior, Intervention, Response, Plan [BIRP]).
B. Treatment Plan: (a 1/2-page chart):
Regardless of the progress note format you choose (SOAP, DAP, BIRP), the “P” represents your plan for treatment. Use the following format for the “P” section. (Although you may identify modalities other than individual counseling, you will only provide the individual counseling piece of the intervention.) You must identify two to three goals with two to four objectives for each goal. The treatment plan should reflect an integration of your understanding regarding the clientâ€™s needed treatment focus, his/her strengths to build upon, his/her diagnostic issues or therapeutic challenges, your theoretical orientation or model of counseling, evidence-based practice, and appropriate modalities for treatment (note: the plan may include modalities other than individual counseling, such as group, family, advocacy, etc., but you must have individual counseling as one modality since you will be demonstrating and documenting these sessions).
Treatment Plan Format: Use the following table format for your treatment plan. (Although you may identify modalities other than individual counseling, you will only provide the individual counseling piece of the intervention. Identify 2-3 goals.
|Problem||Goals||Objectives||Modality & Frequency|
|List one of the major problem areas identified for the client (e.g. depression, stress, etc.).||Goal 1: Provide 3 treatment goals that are realistic, manageable, behaviorally observable, and measurable.||Provide 2-4 objectives for each treatment goal. These should integrate the language of your theory and/or evidence-based practice related to the clientâ€™s diagnostic and therapeutic issues.||
Indicate the recommended modality and frequency. Modalities include individual, group, family, therapeutic milieu (residential), play therapy, advocacy/case management, psycho-education, psychiatric evaluation/intervention, etc.
*Specifically identify: Multidisciplinary treatment modalities such as the use of caseworker, school counselor, probation officer, or psychiatrist when appropriate.
|List a second problem area that was identified…||Goal 2:|
C. Risk Management Plan: (1/2 a page):
Identify potential areas of risk for this client. Discuss specific, culturally appropriate risk assessment and risk management plans for the client. This may include self-harm, harming others, or decomposition related to mental health issues.
D. Case Conceptualization: (1/2 a page):
Document the case conceptualization, integrating diagnostic, developmental, sociocultural, interpersonal, neurobiological, and theoretical concepts into your understanding of the clientâ€™s issues. Integrate feedback from your case consultation session.
E. Self-Reflection: (approximately 1â€“2 pages):
You are to use the Interpersonal Process Recall method of self-supervision following the session and document notes of your self-supervision. Integrate the information from self-supervision and case consultation into your self-reflection this week. Identify your strengths and challenges as a counselor. Specifically note any ethical, legal, or sociocultural issues that might be a focus for supervision and any transference or counter-transference issues that may be affecting the therapeutic relationship.
Identify any self-care concerns and/or concerns related to potential vicarious trauma. Discuss your plan for self-care as a counselor, even if only to discuss time and stress management regarding balancing your career and personal life.
Explain your ability to be present with the client. Include your experience of being present and the impact you believe it had on the client. Describe your experience as a participant-observer in the relationship. Lastly, include any specific advanced skills you utilized this week and how you felt in terms of self-efficacy applying those skills.
Your final product will be a Microsoft Word document, written in APA format, and be approximately 3â€“4 pages in length. Your report should be written in a clear, concise, and organized manner; demonstrate ethical scholarship in the accurate representation and attribution of sources; and display accurate spelling, grammar, and punctuation.
Module 4 Overview
- Identify and assess counselor characteristics and behaviors that influence the helping processes.
- Apply advanced counseling skills and develop case conceptualizations to facilitate client progress.
- Analyze clients’ mental status, diagnostic information, and presenting problem to develop strength-based treatment goals and strategies to promote client wellness.
- Recommend appropriate and culturally relevant multidisciplinary techniques as appropriate to their client.
- Distinguish between different models of counseling supervision and consultation, and apply appropriate models in practicing peer supervision skills.
- Identify and analyze counselor role and potential biases or counter-transference issues related to client advocacy and multiculturally appropriate intervention.
In this module, you will learn more about the concept of resistance and how to work with it effectively (including some ways to reframe resistance and related concepts as normal and expected processes). You will also explore two specific models that you can use with clients in the future that have been found to be particularly effective in motivating change: motivational interviewing and solution-focused therapy.
Video “What is Solution-Focused Therapy? (Solution-Focused Brief Therapy)” from Dr. Todd Grande via YouTube â€“
Video “Introduction to Motivational Interviewing” from Bill Matulich via YouTube
In this module, you learned about different ways in which to understand the concept of resistance, and you also explored some specific ways in which to motivate change in clients.
Your assignment will give you an opportunity to construct a Treatment Plan that is consistent with motivating change.