By 5th session maximum

Review as often as needed, but needs to be reviewed once every 6 months

Presenting issues: what are they coming to therapy for; strengths; supports that they may have

Diagnosis: DSM V- if it will cause harm to your client, then don’t fill out

Clinical rational is completed for you

Therapy type

Frequency: for the most part weekly, can be 45min or 60min

Client Goals: in client's own words; what do they want to most get out of therapy

Long Term Goal: in clinical sense, what are they working towards

Short Term Goal: most likely will be achieved within the next 6 months

Smart interventions: something that is measurable; tangible way to measure when symptoms have improved; can be general (ex. baseline of 6/10 daily anxiety to average 2/10 anxiety for 2 week period in a row)

Treatment plan must be signed by person consenting: adult will sign for themselves; for minor it will be signed by whomever consented

Room for 3 short term goals: if less than 3, put N/A

Prognosis: how do you feel they are going to do