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
The young people explained that their prominent LGBTQ-associated struggle was with identity confusion
and self-non-acceptance, and that this was closely related to experiences of and worries about stigma and
non-acceptance from others. They also said that a pertinent protective factor was building connections
with similar and accepting others, and that therapists need to help more with these area

Clinical Psychologist Name Clinical Psychologist Signature Date

Pearl Chiam

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

Interview
Client concern
 Ask about sexual orientation (bi/homo)
 詢問個案希望別人如何看待自己
 詢問個案認不認同其生理性別（gender role）、有無性別認同（gender identity）的狀況
 （考量有無 gender dysphoria，也許可以從有無想要成為另一個性別角色做詢問）
 性別認同是指一個人本身對自己所屬性別的主觀的自我概念...個人認定自己的性別是男性還是女性
 性別角色則是表現在外的行為男性化或女性化

Appearance and behaviors 若有需要，可以追溯性角色發展史

（興趣、遊戲方式、打扮喜好、有無討厭自己的性器官、是否偏好和另一性別做朋友、期待被對待的方式等）

Health Status
 有無自殺的念頭/如何應對不舒服情緒？
 睡眠/食慾狀況

Family dynamic and relevant history, social support system

 家裡有無精神科就診史（R/O psychosis）

Social support system

 家庭關係/感情關係/人際關係

Work / Academic
 在學校的成績怎麼樣，有沒有比較喜歡哪些課程

Intake assessment / Suggestion Treatment

Draw A Person Test
DBT emphasizes the teaching of skills to manage emotions, improve
relationships, and reduce emotional reactivity
Mindfulness/emotion regulation/distress tolerance skills
□ Follow up at
□ Clinical Psychologist in charge
Increasing capabilities by teaching specific skills for
self-regulation (including emotion regulation and
mindfulness), interpersonal effectiveness, distress
tolerance, and balanced thinking and acting (“Walking
the Middle Path”)
 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