Individual Treatment Plan Outline

Question 1

What must be included in Question 1?

Answer 1

Firstly, I would go over informed consent with the client and explain the limits of confidentiality.

Secondly, I would inform the client that I am an MFT trainee who is working under the supervision of a licensed marriage and family therapist.

I would inform the client that I will be consulting with my supervisor on a regular basis to ensure that I am competent to treat her.

In addition to counseling, I will consult with my supervisor about possibly referring the client to a psychiatrist for medication evaluation to collaborate and give her the most effective treatment.

Since the client is legally an adult, she can consent to treatment for herself.

I would be sensitive to any aspects such as age, gender, ethnicity, or culture that may influence or impact the therapeutic alliance. For example, since I am not BLANK, the client may have trouble relating to me. I would use my person-centered skills such as empathetic listening and non-judgmental stance to build a foundation for a strong therapeutic alliance.
I would present with warmth and patience to build trust in order for her to feel comfortable sharing with me.

Include collaborative, genuine, empathy, commend despite reservations

Anything specific to the client’s issues

Any legal or ethical issues to address (i.e. consent to treat minor, mandated reporting etc.)

Question 2

What must be included in Question 2?

Answer 2

Identification & history of presenting problems:

• Legal history, Psychological history, Substance abuse, Medical history
• 6 more symptoms
• Group symptoms by category
• Include FIDO info
• IF SI or HI, list here

Question 3

What is crisis plan for SI?

Answer 3

I would carefully assess the client for suicidal ideation, plan, intent, and means.

If she said yes to this, then this.
I would monitor the client’s suicide ideation weekly in order to assess her safety.

If her suicide ideation escalates to having a plan and intent, I would consider either voluntary or involuntary hospitalization.

I believe her suicidal ideation can be managed with supportive therapy. This would possibly include creating a no suicide contract with her, a plan to prevent suicide, and helping her identify supportive individuals and groups she may turn to if she feels sad.

Question 4

What is crisis plan for alcohol/drug use?

Answer 4

I would assess to see if alcohol/drug use is causing significant distress/impairment.

I would assess alcohol/drug use:

• Type of alcohol/drug
• How often/how long/how much (dependency/tolerance)
• Doing it alone/socially
• Types of effects experience/withdrawal

Educate client about alcohol/drug use during therapy – can be a barrier to successful treatment

Refer client to support program (e.g., AA, NA) in addition to weekly psychotherapy

Monitor alcohol/drug use weekly to assess for maladaptive patterns that impair client

If alcohol/drug use is problematic, refer to substance abuse treatment program

Question 5

What is the crisis plan for DV?

Answer 5

Primary goal would be to protect the client (and children).

I would assess for immediate threats or other issues that may impair safety (i.e. children witnessing DV).

Provide resources such as medical, legal, community, and social.

I would educate victim regarding his/her right to safety and level intervention (e.g., file police report, restraining order)

I would provide victim with information for a shelter

Refer client to groups for battered women

Develop and implement safety plan to protect client (and children)

Educate client about cycle of abuse

Question 6

Describe the procedure for mandated reporting.

Answer 6

Child abuse
-Any suspicion make a report to CPS immediately or as soon as it is practicably possible by telephone and send a written report within 36 hours of receiving the information.

Elder/dependent adult abuse
-Must report the known or suspected instance of abuse/neglect by telephone immediately or as soon reasonably possible, and by written report sent within two working days.

Question 7

What must be included in the intervention section?

Answer 7

• INTRO
• WHY WITH THIS CLIENT
• INTRODUCE BY EXPLAINING RATIONAL/GIVE IT A TRY
• EXPLAIN HOW TO DO IT BY FILLING IT OUT WITH THEM
• LIST SIMPLIFED STEPS
• TALK ABOUT HOW IT WAS FOR THE CLIENT
• EXAMPLE WITH THE CLIENT
• HOMEWORK, WILL BE CHECKED ON THE NEXT SESSION

Question 8

Referrals

Answer 8

MEDICATION→ DEPRESSION Moderate+, PTSD, PANIC, ADHD, BIPOLAR, OCD AND PSYCHOSIS.

MEDICAL DOCTOR REFER→ EATING DISORDERS