TREATMENT PLAN

Basic Information
Name Diagnosis Date of Birth Age Gender Highest Education

Specific problem/behavior
□ ADHD □ Eating issues □ Panic/Anxiety Attack
□ Alcohol/Substance abuse □ Fearful □ Poor impulse control
□ Attempt to harm others □ Grief □ Self-harm behavior
□ Anxiety □ Hallucination □ Sexual issues
□ Conflict of Identity □ Interpersonal conflict □ Sleeping issues
□ Compulsion/Obsessions □ Lack of judgement □ Stressor: ______________
□ Conduct disorder problem □ Low self-esteem/self-concept □ Suicide intention
□ Delusion □ Lack of interpersonal skills □ Somatoform issues
□ Disorganized thinking □ Life adjustment □ Trust issues
□ Depression □ Oppositional defiant problem ■ Others: _______________
Treatment Plan
Client concern

Short-term goals for treatment Long-term goals for treatment

Intervention (and estimated time of psychotherapy)

Case formulation

Clinical Psychologist Name Clinical Psychologist Signature Date

Pearl Chiam

AUTISM INTAKE ASSESSMENT

Crisis: □ Y □ N Date of Interview Clinical Psychologist Name
 Pearl Chiam

Interview
Parents/teachers concern (Specific social functioning that are doing too much or doing too little)
A (Antecedent of the situation/setting before the behavior issue) / B (Behavioral excess or missing behavior) /
C (Consequence: what happened after the behavior)

Target relevant social skills

 Consider the settings in which we hope the student will function successfully.
 Have parents and teachers consider what the student does too much of or too little of on a daily basis that interferes
with social functioning in those settings.
 Understand the student’s point of view and preferred ways to solve problems in those settings.
 Use the social skill menu as a guide to identify critical skills that may be part of the solution.
 Articulate a user-friendly number of skill goals (three to seven) to work on at a time.

The Client (Review his strength and special interests): Is the student motivated to learn or use new skills?

Personal values and mental flexibility assessment

Intake assessment / Suggestion Treatment

□ Follow up at
□ Clinical Psychologist in charge
Pearl Chiam .
DAILY COUNSELLING NOTES
Case No Name Session No

Attendance Attendance
□ Punctual □ Late for _____ minutes □ Alone
□ Cancelled before appointment □ Did not show up □ Accompanied ( _______________ )
Observation Note Meditation
□ Comfortable □ Anxious □ Defensive □ Aggressive □ Yes ( _______________________ )
Note □ No
 □ Domestic Violence □ Suicide (Idea / Attempt)
□ Sexual Abuse □ Drug Abuse
Subjective

Objective

Assessment

Plan

Note

Rescheduled Clinical Psychologist Signature

Subjective: This section contains information relevant to what the client reveals in the session. This may be
the client’s chief complaint, presenting problems and any relevant information. This information may
include direct quotes from the client and things discussed during the session.

 Subjective soap note example: You may have discussed your client’s complaint of not sleeping
well and sleep hygiene. Use words like “Discussed” or “talked about” or “reviewed” when
describing things talked about in session.
 Question to ask:
 What are the core problems the client believes they are facing?
 What symptoms and resulting life challenges did the client report?
 What history and context did the client report that would be essential to include?
 What specific statements did the client make that help illustrate their current experience?
Objective: The objective section contains factual information. Such objective details may include things
like a diagnosis, vital signs or symptoms, the client’s appearance, orientation, behaviors, mood or affect.

 Objective soap note example: Client is oriented x4 (person, place, time, situation), client appears
dishevelled.
 Question to ask:
 What were the behaviors, nonverbal expressions, gestures, postures, and overall presentation
of the client?
 What was the client’s mood and affect?
 What was the nature of the client’s thought processes, thought content and orientation to their
environment?
 How did the client respond during the session and during particular topics of discussion?
 What assessment scores were recorded or discussed during the session?

Assessment: This section is the place where you, as the clinician, document your impressions and
interpretation of the objective and subjective information. This documentation may include clinical
impressions related to factors such as mood, orientation, risk of harm as well as assessment of progress
towards goals. Here you want to describe your impressions.

 Assessment SOAP note example: The client appears to understand the new goal.
 Question to ask:
 Which clinical themes are present?
 What diagnostic criteria are being met by the client?
 What do the subjective reports of the client and objective observations really show about the
current state of the client?
 Are there any rule out diagnoses that should be noted?

Plan: This section documents what the next step is for the client. What do you, as the clinician, plan to do
with the client at the next session? This is also the place to document things like the anticipated frequency
and duration of therapy, short and long term goals as well as any new goals. Be sure to note any homework
assignments or tasks you’ve given your client.

 Plan SOAP note example: Give referral

 Question to ask
 What progress or lack of progress has the client made towards their self-determined goals?
 What specific steps has the client committed to work on as homework or during the next
session?
 What specific interventions or treatment plan changes will the clinician be focused on in the
upcoming sessions?
 It sounds like an easy format to follow, but it does take some practice.

Therapy Soap Note Example #1

Subjective
Client reported ongoing worry and anticipatory anxiety. They stated “It is hard for me to get excited to go
anywhere because I’m always expecting the worst.” They also noted extreme restlessness, muscle tension
and an average of 3-4 hours of sleep per night.

Objective
Client’s speech was rapid and rambling. Their thought processes were tangential. They frequently avoided
discussing their anxiety by diverting to unrelated topics of discussion. They were fidgety throughout the
session. Their mood was anxious with congruent affect. They denied any SI/HI or psychosis. They were
oriented x 4. Writer conducted the GAD-7 assessment with the client and reviewed the severe score result of
18 with them.

Assessment
Client continues to experience severe symptoms congruent with their Generalized Anxiety Disorder
diagnosis. Their frequent rumination, hypervigilance, physical distress and worry is disruptive to their self-
care, social life and occupation. Writer will continue to assess for the possibility of Social Anxiety Disorder
given client’s previous mention of anxiety related relational difficulties.

Plan
Client has made minor attempts to implement some of the coping skills discussed with Writer but continues
to present with an overall avoidance of deeper intervention for their anxiety. Client has not conducted
previously agreed upon homework activities. Writer will continue to build rapport and trust with the client.
Writer will provide basic anxiety psychoeducation and teach mindfulness based relaxation techniques.
Writer will introduce the model of CBT to help prepare the client for deeper work on their anxious
cognitions, behaviors and emotions.

Therapy Soap Note Example #2

Subjective
Client complained of depression and low self-esteem. She endorsed symptoms of low motivation, lack of
interest in activities, social isolation, guilt and shame, low mood, loss of appetite and inability to
concentrate. She reported experiencing these symptoms consistently for the past seven months. Client
reported “I’ve never felt this sad before. It feels like I can’t get myself motivated to do anything that I used
to do.”

Objective
Client participated in the video telehealth call from her home. The address is on file. Client presented as
disheveled and conducted the appointment while still lying in her bed. She wavered between looking at the
camera and lying on her back looking up at the ceiling. Client’s speech was slow and halting. Her attention
and concentration were within normal limits. She was forthcoming with information and displayed
reasonable insight. She denied any HI or psychosis. She reported passive SI last week but denied any
current SI, plans or intent. Writer encouraged her to call 911 or 988 if her SI intensifies and causes concern
for her safety. She acknowledged this.

Assessment
The Client meets full criteria for Major Depressive Disorder. Her physical health and relationships are
significantly impacted by the severity of her symptoms. The client’s mood and activity levels have declined
in recent weeks. She has not reported or displayed any signs of mania and thus has not met criteria for
Bipolar I or II.

Plan
The Client will benefit from behavioral activation. Writer will provide education about the MDD diagnosis,
CBT and the benefits of behavioral activation for early stages of depression treatment. Writer will work
with Client to develop an initial weekly plan of activities.

Therapy Soap Note Example #3

Subjective
Client continues to participate in therapy to deal with symptoms of acute stress related to a recent car
accident. He reported ongoing intrusive symptoms of nightmares, flashbacks and triggering reminders of
the event. He noted avoidance of all driving and avoiding travel by roads as much as possible. He stated “I
haven’t driven again since the accident. I don’t know if I will ever be able to drive again.” He reported
ongoing challenges with hypervigilance, low mood, sleep difficulties, startle response, irritability, social
isolation, shame, self-blame and inability to think positively about the future. Client reported that the
symptoms have harmed his relationship with his partner.

Objective
Client was given the PCL-5 assessment and scored a 49 which Writer reviewed with the Client. Client
appeared uneasy, uncomfortable and hypervigilant during session. He frequently shifted positions in his
chair, picked at his nails and anxiously looked out the window. His mood was anxious with congruent affect.
His speech, thought processes and thought content were normal. His insight and judgment were fair. Client
was cooperative but was guarded at times when speaking about memories of the accident.

Assessment
Client continues to experience the symptoms of trauma and acute stress. His symptoms directly correlate to
the recent car accident that occurred three weeks ago. These symptoms were not present in his life prior to
the accident. His relationship issues, emotional difficulties and avoidance behaviors all started immediately
after the accident. He meets full criteria for Acute Stress Disorder and will be reassessed after 1 month
post-accident to determine if he meets criteria for PTSD. He shows good insight and is receptive to
therapeutic intervention.

Plan
Client has been receptive to education and initial stabilizing coping skills taught by Writer. Client has
started to utilize the coping skills despite being frustrated by his persisting trauma symptoms. Writer and
Client have discussed EMDR therapy and agreed to begin the intervention as soon as possible. Writer has
explained risks and benefits of EMDR to client. Writer will begin initial preparation phases of EMDR, while
continuing to assess client’s stability and capacity to tolerate difficult emotions.