COUNSELING PRACTICUM CLINIC

TREATMENT PLAN
Original (First Tx. Plan)
Revised or Updated

Date Completed
Client ID #

Counselor Name:
Client or Family Name:
Note: A treatment plan is to be completed before the fourth session.
Presenting Problem

Symptoms of depression related to adjustment; and career

Specific Definitions of Presenting Problem

1.
2.
3.
Long Term Goals
1.
2.
3.
Short-Term Objectives
1.
2.
3.
4.

Therapeutic Interventions
1.
2.
3.
4.
Expected Length of Treatment
complete other side -->

DSM IV DIAGNOSIS
AXIS I: Clinical Syndromes or Other Conditions That May be a Focus of Clinical Attention:
DSM IV Code DSM IV Name

AXIS II: Personality Disorders/Mental Retardation:

DSM IV Code DSM IV Name

AXIS III: General Medical Conditions

ICD 10 Code
Name

AXIS IV: Psychosocial And Environmental Problems (Check Those that Apply and Specify by
Providing Additional Information)
Problems with primary support group
(Specify)
Problems related to the social
environment (Specify)
Educational problem (Specify)
Occupational problem (Specify)
Housing problem (Specify)
Economic problem (Specify)
Problems with access to health care
services (Specify)
Problems related to interaction with
the legal system/crime (Specify)
Other psychosocial and environmental
problems (Specify)
AXIS V:
Global Assessment of Functioning Scale (Score)
Global Assessment of Relational Functioning (Score)
__________________________________
Counselor's Signature
I have reviewed the above treatment plan and find it appropriate considering the information
known.
__________________________________
__________________________________
Signature of Faculty Supervisor
Date Signed