Table of Contents

CAVEATS............................................................................................................................................................. 2
DIAGNOSTIC CONCEPTUALIZATION...................................................................................................................... 3
DIAGNOSTIC CONCEPTUALIZATION EXAMPLE– ADULT..........................................................................................................3
DIAGNOSTIC CONCEPTUALIZATION EXAMPLE – YOUTH........................................................................................................5
CASE CONCEPTUALIZATIONS............................................................................................................................... 8
CMHC CASE CONCEPTUALIZATION TEMPLATE...................................................................................................................8
SC CASE CONCEPTUALIZATION TEMPLATE.......................................................................................................................12
CASE CONCEPTUALIZATION EXAMPLE.............................................................................................................................17
FORMS.............................................................................................................................................................. 19
ABUSE AND/OR NEGLECT FORM EXAMPLE......................................................................................................................19
ADAPTED TRIAGE ASSESSMENT FORM (TAF) TEMPLATE....................................................................................................20
TREATMENT PLANS........................................................................................................................................... 24
BOOKS WITH MANY TREATMENT PLAN EXAMPLES............................................................................................................24
PROGRESS/CASE NOTES.................................................................................................................................... 25
BOOKS WITH MANY EXAMPLES OF PROGRESS/CASE NOTE EXAMPLES..................................................................................25
BIRP NOTE EXAMPLE.................................................................................................................................................26
DAP NOTE EXAMPLE..................................................................................................................................................27
SOAP NOTE - CMHC EXAMPLE...................................................................................................................................28
SOAP NOTE – SC EXAMPLE........................................................................................................................................29
TREATMENT SUMMARY/ DISCHARGE................................................................................................................ 30

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 Caveats

1) Documentation is an ethical and legal responsibility. Failing to comply with documentation

requirements often result in audit paybacks, fraudulent findings etc. Counselors can reduce their
risk of going to court or having a licensing board involved with concerns by complying with
documentation requirements. Unfortunately some the most skilled clinicians often fail on
paperwork.

2) Documentation requirements vary based on a specific therapist, agency, healthcare setting,

state laws, county laws, payor sources, etc. but documentation must to comply with:
a. Ethical Codes
b. Accrediting bodies
c. State laws and compliance standards (e.g., department of Medicaid)
d. County Behavioral Health Boards, and/or
e. Agency policies and procedures, managed care systems, private insurance, and payer
sources.

3) The Golden Thread runs through all documentation. The Golden Thread is consistent
presentation of relevant information throughout counseling and documentation; it is the basis
for all parts of the counseling process and is based in the theoretical orientation of the
counselor. The Golden Thread must be woven throughout the diagnostic assessment, treatment
plan, progress notes, termination summary and any other documentation; documentation
relates to and builds upon other documentation, providing justification for the interventions
used. Clearly documenting the golden thread creates a comprehensive story of the counseling
process as well as assist any billing or payment for the counselor.
a. Treatment planning starts with the diagnosis/symptoms; goals & objectives are directly
tied to the diagnosis
i. For example someone with Major Depressive Disorder should have goals and
objectives related to symptoms of Major Depressive Disorder, not
Schizophrenia.
b. Goals & objectives from the treatment plan should be reflected in the interventions
used and documented in progress notes
i. For example someone with Major Depressive Disorder should have
interventions related to symptoms of Major Depressive Disorder, not substance
use

4) School Counselors use American School Counseling Association (ASCA) templates. School
counseling students need to be aware of these common styles, however best practice is to use
ASCA templates for all professional documentation with students. The ASCA templates can be
found at https://schoolcounselor.org/About-School-Counseling/ASCA-National-Model-for-
School-Counseling-Programs/Templates-Resources

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 Diagnostic Conceptualization
Diagnostic Conceptualization Example– Adult
Client Name
Jane*
Case Conceptualization
(Note: Include specific information about client symptoms and presenting concerns.)
Jane is a 35-year-old Caucasian female who self-referred for treatment. Jane reports experiencing
feelings of withdrawal, sadness, and hopelessness. She stated that she has struggled to maintain
relationships and has lived with her mother her entire life. Jane's relationships are often volatile and
characterized by others viewing her as "needy", "dramatic", "emotional" and "crazy. " Jane declines any
current religious involvement but noted some interest in exploring Buddhism and spirituality.

Jane has a history significant for sexual abuse by her older brother and her brother's best friend. Jane
reported that the abuse took place from the ages of 4 to 14 and stopped only when her brother left
home. Jane reported that she has never disclosed the abuse to her mother. Jane has experienced
instability in relationships with friends, and reported no support system beyond her mother. Jane
struggles with individuation and often internalizes the interests of her others.

Jane tends to think very concretely and she struggles with a general negative outlook. She has a past
history significant for severe self-injury (i.e., self-cutting). She's also had periods of suicidal thoughts but
she reports no current suicidal ideation at the time of session. Jane also has a history of disordered
eating but she reports that she has not engaged in any binge/purge behavior for approximately the past
several years.

Jane's medical history includes previous diagnoses of Major Depressive Disorder and Posttraumatic
Stress Disorder. She has been diagnosed with asthma. Jane reports that she has the ability to induce an
asthma attack and she admitted to doing so at least twice weekly over the course of the past year in an
effort to seek medical care. Jane reported that she enjoyed the attention associated with medical care.

Jane has a history of inappropriate boundaries with her previous counselor and she acknowledged going
to great lengths to obtain her previous counselor's home address so that she could drive by her house.

Jane has previously attended college but is not currently enrolled. She was the first individual in
her family to attend college and she reports that her mother was not supportive of her
education. Jane reported that she would like to eventually return to school but she fears that
she will be able to complete her studies until her medical care is addressed.

Diagnostic Impressions
(Note: Be sure to use the ICD-10 code, name of the disorder, and all of the specifiers.)

F60.3 Borderline Personality Disorder (Reason for Visit)

F33.1 Major Depressive Disorder, Recurrent, Moderate, Provisional
F43.1 Posttraumatic Stress Disorder, Provisional
Rationale for Diagnostic Impressions
(Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic

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 criteria for each diagnosis that you render. If you do not render a diagnosis, you still must use
the DSM-5 to explain why you chose not to render a diagnosis.)
Jane's medical history includes past diagnoses of F33.1 Major Depressive Disorder, Recurrent, Moderate
and F43.1 Posttraumatic Stress Disorder, Provisional. Based on her current presentation, it appears that
reason visit is related to symptoms of F60.3 Borderline Personality Disorder.

Consistent with the symptoms of Borderline Personality Disorder, Jane demonstrates a pervasive pattern
of instability in multiple facets of her life that appears to have begun in late adolescence. Jane reports
that those with whom she has had relationships have called her "needy" and she indicated that her
relationships tend to vacillate between ideation and devaluation (Criterion 2). Jane reported that she
doesn't feel connected to a particular identity and she often takes on the identity of those in her life
(Criterion 3). Jane has recurrent suicidal thoughts and self-injurious behavior (Criterion 5). She also
experiences affective instability and her mood appears reactive to those around her (Criterion 6). Jane
reports feeling empty and she often struggles to find meaning in her life (Criterion 7). Jane is prone to
bouts of anger, especially in response to situations in which she feels out of control - for example,
slashing a friend's tires after a fight (Criterion 8).

In order to qualify for a diagnosis of a personality disorder, an individual first must meet the General
Criteria for a Personality Disorder. Jane's symptoms have been evident since at least age 20, which
suggests that her symptoms represent an enduring pattern of behavior that have impacted her thoughts
(“If there were a God, he wouldn’t have let my life turn out this way”; Criterion A1), her affect
(characterized by overwhelming feelings of sadness and hopelessness; Criterion A2), her interpersonal
functioning (volatile relationships with friends; Criterion A3), her impulse control (a history of self-injury
and bulimia; Criterion A4). Jane's symptoms have been evidenced in numerous situations (e.g., work,
school, home; Criteria B) and the symptoms cause clinically significant distress across numerous areas of
her life (e.g., home, relationships, work, school; Criteria C). Jane's symptoms appear to have begun in late
adolescence (Criteria D). The client has asthma; there are no other medical conditions that are
responsible for her current symptoms (Criteria E). Client was prescribed Paxil but there is no evidence of
substance use and thus, no evidence that substance are causing her symptoms (Criteria F).

The client reports that she has previously been diagnosed with F33.1 Major Depressive Disorder,
Recurrent, Moderate and F43.1 Posttraumatic Stress Disorder. The client's current presentation does not
provide enough evidence to support rendering either diagnosis at this time. However, based on the
client's past trauma history and her self-reported "dark times", both disorders warrant further
exploration.
Cultural and Ethical Considerations
(Note: Include information that may be pertinent to the diagnosis.)
The client does not have any current religious involvement but she reported some interest in pursuing
Buddhism. The client is a first generation college student and she reports limited support for pursuing
her education from her friends and family. The client has a limited social support system and spends the
majority of her time with her mother.

Jane is not currently sexually active and she reports discomfort with the idea of intimacy. She appears to
feel more comfortable with females; however, she is not currently in a relationship and does not appear
to be actively seeking out romantic partners.

The client has a history of inappropriate boundaries in relationships. The client previously engaged in

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 stalking-type behavior toward her previous therapist. Thus, it is important that boundaries are enforced
for the duration of the counseling relationships.

Student Name and Credentials (e.g., Frida Kahlo, B.A.) Date

Victoria Woodhull, B.A. 07/04/23
*Note: Case Available in Chapter 9 of Kress, V.E., & Paylo, M.J. (2018). Treating those with mental disorders: A
comprehensive approach to case conceptualization and treatment (2nd ed.) New York, NY: Pearson

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Diagnostic Conceptualization Example – Youth
Client Name
Javier
Case Conceptualization

(Note: Include specific information about client symptoms and presenting concerns.)
Javier is a 17-year-old Hispanic male who received a referral for treatment from a physician.
Javier was seen by his general physician for presenting concerns related to fatigue. Per the
physician’s referral, all lab results were normal. Javier has signed consent forms for mom to
participate in the intake interview.

Javier is a junior in high school. Both Javier and his mom report that over the course of the
last few months, Javier has become withdrawn and does not interact with family and friends.
Javier reports that he has a generally depressed mood, lacks interest in any activities, and is
often irritable and easily angered. When asked about his social life, Javier reports that he
doesn’t have any friends and isn’t involved in any school sports or activities. In 9 th and 10th
grade, he was involved in art club, and he ran for the Cross Country and Track teams, but quit
participating in all of these activities. He says that he has difficulty sleeping at night, so he
plays video games and then eventually falls asleep right before having to get up in the
morning.

Javier has been struggling with a generally negative outlook and feelings of hopelessness.
He reports that he knows that he needs to complete his schoolwork but isn’t motivated to
complete tasks and feels like everything in life is pointless. He reports that when he does try
to do his homework, but he can't focus, he gets frustrated and angry, and then gives up. This
happens most often with large assignments specifically with math or writing assignments. He
says that his mom wants him to go to college, but he doesn’t know what he wants to do in
the future, and he isn’t interested in anything career related. He reports that for the last
three months, he also has experienced periods of suicidal thoughts, but he indicated that he
has no current suicidal ideation at the time of session.

Based on the reports from his mom, he has had a decline in his academic progress. She
reports that his grades have dropped from B and C’s to D's and F's. Mom reports that he has
difficulty getting out of bed, stays in his room for long hours, and often refuses to go to
school. Mom also reported that he isn’t turning in his schoolwork and that he appears to be
very distracted and disengage in class.

Javier's medical notes indicate a previous diagnosis of Generalized Anxiety Disorder (F41,1)
with reported symptoms of sleep disturbance, excessive worry, and difficulty concentrating.
Javier’s mom indicated that this occurred when Javier transitioned to middle school, but he
was not prescribed medication. Other medical diagnoses include allergies and asthma, but
no other health conditions have been reported.

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 Educational/Academic Concerns

(Note: This section should be considered for K-12 youth. Include information on the impact
of client symptoms and presenting concerns on the following domains: Academic,
Social/Emotional/Behavioral, and Career/College Planning.)
Javier is a minor and attends public high school. Symptoms appear to be impacting the
client’s ability to participate in school and meet daily educational expectations. The following
includes school-based concerns using the domains: Academic, Social/Emotional/Behavioral,
and College/Career Planning.

 Presenting Concerns- Academic: Based on parent reporting, Javier is experiencing

challenges in his academic progress including a decline in grades and attendance
concerns.

 Presenting Concerns- Social/Emotional/Behavioral: Based on parent and student

reporting, student is experiencing challenges with motivation and future planning. In
addition, there are additional concerns about student withdrawing from social
interactions.

 Presenting Concerns- College/Career: Javier reported that he is unable to develop

goals for future planning and feels pressure to go to college.

Collaboration with the school counselor should be considered to identify additional concerns
and resources in the educational environment. Consider obtaining consent form to speak
with school counselor for collaboration, interventions, and progress monitoring.

Diagnostic Impressions

(Note: Be sure to use the ICD-10 code, name of the disorder, and all of the specifiers.)

F32.1 Major Depressive Disorder, Single Episode, Moderate

Rationale for Diagnostic Impressions

(Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic
criteria for each diagnosis that you render. If you do not render a diagnosis, you still must use
the DSM-5 to explain why you chose not to render a diagnosis.)
Javier’s medical history includes a previous diagnosis of Generalized Anxiety Disorder (F41.1).
Based on his current symptoms, it appears that the reason for the visit is related to (F32.1)
Major Depressive Disorder, Single Episode, Moderate.

Consistent with symptoms of Major Depressive Disorder, Javier’s symptoms include

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 depressed mood with feelings of hopelessness (Criterion A1), diminished interest in activities
(Criterion A2), daily fatigue (Criterion A6), feelings of worthlessness (Criterion A7), thoughts
of suicide without a plan (Criterion A.9), and difficulty concentrating. (Criterion A.8).
Symptoms are impacting client's attendance and participation in school, homework
completion, and social interactions (Criterion B). Based on medical history and client
reporting, the symptoms to not appear to be related to substance use or other medical
conditions. Symptoms have been present for several months.

Based on the DSM 5, to qualify for a diagnosis of Major Depressive Disorder an individual
needs to meet the criteria of five or more symptoms within a 2-week period and have
symptoms including loss of interest or depressed mood. In addition, symptoms must impact
areas of functioning and not attributed to other medical or substance use conditions.

This is the first occurrence and symptoms are impacting client’s ability to attend school;
however, client reports he is still attending school when he is able; thus, the diagnosis fits
with single episode and is moderate.

The client reports a previous diagnosis of Generalized Anxiety Disorder (F41.1) based on
current symptoms, the criteria more closely qualify for Major Depressive Disorder, Single
Episode, Moderate

Cultural and Ethical Considerations

(Note: Include information that may be pertinent to the diagnosis.)

Javier and mom report that his father has not been in the picture since before Javier was
born. Javier is an only child and is often home alone while mom works late hours. Javier will
be a first-generation college student, and he reports that mom expects him to pursue a
college education. Javier indicated that he wanted to make his mom happy and doesn’t want
to disappoint her but feels pressure to follow her dreams.

Per Javier, he and his mom have been living in the same home and within the same
community. They used to attend church regularly when Javier was young, but he and his
mom have not attended in recent years. Javier’s grandparents live a few blocks away. Javier
reports that he has always been close to both of his grandparents.

Student Name and Credentials (e.g., Frida Kahlo, B.A.) Date

Symphony Johnbull, B.A. 07/04/22

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 Case Conceptualizations
CMHC Case Conceptualization Template

Counselor name: Client age:

Client initials: Client race or ethnicity:
# of sessions with client: Self-identified gender:

Presenting Problem
To understand the presenting problem, describe the client's past and present. Be sure to address each
of the following elements:
 Demographic information
 Employment history
 Relevant legal problems
 History of counseling
 Reason for seeking counseling, according to the client
 Onset and duration of concern
 Frequency and intensity of symptoms
 What the client wants to improve

Your discussion of the Presenting Problem should include 3–4 well-formed paragraphs. In
response to the prompts above, begin typing here:

Family Structure
Clients and their concerns are shaped by their family structure and stage of development. Be sure to
address each of the following elements and their impact:
 Family of origin and role within
 Family of choice if different and role within
 Significant relationships/relationship patterns
 Children, marriages, divorces
 Current living arrangements
 Major losses, traumas
 Family mental health history
 Family substance abuse history
 Family violence or abuse history
 Stage of development impacts
 Developmental challenges

Your discussion of Family Structure should include 3–4 well-formed paragraphs. In response
to the prompts above, begin typing here:

Multicultural Considerations

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Clients and their concerns are shaped by a multitude of multicultural considerations and their
intersectionality. Be sure to address each of the following elements that apply and their impact on the
person, the problem, and the counseling relationship:
 Race, ethnicity
 Religion, spirituality, or faith
 Ability limitations, impairments
 Sexual, affectional orientation
 Cisgender, transgender, or otherwise identified
 Age, generation
 Socioeconomic status, affluence, homelessness
 Military upbringing, involvement, deployment
 Criminal justice system, gang culture, drug culture
 Immigration status, language preference
 Geographic influences, environmental factors
 Experiences of oppression or marginalization

Your discussion of Multicultural Considerations should include 3–4 well-formed paragraphs. In

response to the prompts above, begin typing here:

Narrative Summary
Take a step back and, through the lens of your education to this point, work to conceptualize the big
picture. Consider the influence of all the information in Part I. Consider how it has all culminated and
impacted who your client is and their worldview. Within that context, consider the problem they
presented with for counseling and address each of the following elements:
 Describe your understanding of the problem
 Describe your observations of the client
 Describe your impressions of the client
 Describe any factors contributing to or reinforcing the problem
 Describe the purpose of the client’s behaviors
 Describe themes and patterns that emerge or connect
 Describe barriers to growth and coping
 Describe strengths, assets, protective factors, and signs of resilience

Your discussion of the Narrative Summary should include 3–4 well-formed paragraphs. In
response to the prompts above, begin typing here:

DSM-5 Diagnosis
It is of utmost importance to diagnose ethically and responsibly. You must consider all elements covered
thus far, not only in your understanding of the problem, but in rendering a diagnosis. With this in mind,
address each of the following elements:
 DSM-5 diagnosis
 Rationale for how diagnosis was determined
 Two other diagnoses considered, but not given

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  Explanation for ruling out diagnoses not given
 Mental health assessments or scales used
 Other assessments or scales that could be used

Your discussion of the DSM-5 Diagnosis should include 3–4 well-formed paragraphs. In
response to the prompts above, begin typing here:

Theoretical Orientation and Application

Your theoretical orientation influences your counseling approach. While you are likely still in the very
early stages of considering and trying on different theoretical orientations, you have likely noticed that
some seem to resonate with you more than others. While you have been trained in Person-Centered
Theory, consider another orientation that most closely aligns with your understanding of human
behavior and your approach to it. In doing so, respond to the following:
 State your preferred theoretical orientation and the original theorist
 Describe what elements of this preferred theoretical orientation resonate with you
 Explain how this preferred theoretical orientation approaches client problems
 Explain how this preferred theoretical orientation approaches positive change
 Describe how this preferred theoretical orientation would make sense of your client’s presenting
problem
 Now, select another counseling theory and contrast how it would make sense of your client’s
presenting problem differently

Your discussion of Theoretical Orientation should include 3–4 well-formed paragraphs. In

response to the prompts above, begin typing here:

Treatment Planning
The nature of the treatment plan and evidence-based interventions should coincide with the needs of
the client and the theoretical orientation utilized. Additionally, treatment goals should be SMART
(specific, measurable, attainable, realistic, and timely). Using your theoretical foundation of Person-
Centered Theory coupled with your preferred theoretical orientation described in Part II, respond to the
following elements:
 Short-term SMART goal for treatment
 Interventions, approaches, and techniques to work towards this goal
 Mid-range SMART goal for treatment
 Interventions, approaches, and techniques to work towards this goal
 Long-term SMART goal for treatment
 Interventions, approaches, and techniques to work towards this goal

Your discussion of Treatment Planning should include complete-sentence, bulleted responses

to each of the prompts. In response to the prompts above, begin typing here:

© 2024 Walden University, LLC Page 11 of 33

Ethical and Legal Considerations
Nearly all clients and every situation present the possibility for ethical concerns and dilemmas. It is
important to be proactive and intentional in our consideration of what those might be. Ethical
challenges can arise in a number of ways, including transference/countertransference, court-ordered
counseling, informed consent, boundary violations, poor self-care, limits of confidentiality, and
mandated reporting, to name a few. Using the ACA Code of Ethics, reflect on your work with the client
and respond to the following:
 Describe potential ethical dilemmas present or potentially present
 Identify your own barriers or challenges that may complicate the ethical dilemma
 Explain the steps you should take to be intentional and proactive in your ethical approach

Your discussion of Ethical and Legal Considerations should include 3–4 well-formed
paragraphs. In response to the prompts above, begin typing here:

Social Change Implications

The end of your work with a client should not be the end of your work. Each client impacts us as we
impact them. Reflect on your client and their circumstances. Consider their efforts in relation to their
successes and failures.

The consideration for social change lends itself well to considering referrals (e.g., housing, community
psychiatric support). Social change needs aren't always billable services for a counselor and may not be
within scope of practice. For example, if being unhoused or homeless is a barrier, then the documented
intervention might be "referral to community psychiatric support for assistance with housing needs).
Most likely, a treating counselor cannot bill for calling housing, completing applications ect. Many new
counselors falter in community mental health because they fail to use empirically supported treated
interventions specific to the diagnosis.

Keeping in mind all of the information you have considered for this case and all the insight you have
gained, respond to the following elements:
 Address the systems and barriers the client experiences that impacted the current situation and
outcomes
 If changed or removed, identify what systems and barriers could impact positively upon this
individual in the future
 Discuss how your work with this client has informed your understanding of a larger social
challenge or barrier
 Identify steps you could take to effect positive social change in relation to this social challenge or
barrier

Your discussion of Social Change Implications should include 3–4 well-formed paragraphs. In
response to the prompts above, begin typing here:

© 2024 Walden University, LLC Page 12 of 33

SC Case Conceptualization Template

Counselor name: Student age:

Student initials: Student race or ethnicity:
# of sessions with student: Self-identified gender:

Presenting Problem
To understand the presenting problem, describe the student past and present. Be sure to
address each of the following elements:
 Demographic information
 Employment history
 Relevant legal problems
 History of counseling
 Reason for seeking counseling, according to the student
 Onset and duration of concern
 Frequency and intensity of symptoms
 What the student wants to improve

Your discussion of the Presenting Problem should include 3–4 well-formed

paragraphs. In response to the prompts above, begin typing here:

Family and Developmental Factors

Students and their concerns are shaped by their family structure and stage of development. Be
sure to address each of the following elements and their impact:
 Family of origin and role within
 Family of choice, if different, and role within
 Significant relationships/relationship patterns
 Children, marriages, divorces
 Current living arrangements
 Major losses, traumas
 Family mental health history
 Family substance abuse history
 Family violence or abuse history
 Stage of development impacts, to include Piaget, Erikson, and Kohlberg
 Developmental challenges

Your discussion of Family and Development Factors should include 3–4 well-formed
paragraphs. In response to the prompts above, begin typing here:

© 2024 Walden University, LLC Page 13 of 33

Multicultural Considerations
Students and their concerns are shaped by a multitude of multicultural considerations and their
intersectionality. Be sure to address each of the following elements that apply and their impact
on the person, the problem, and the counseling relationship:
 Race, ethnicity
 Religion, spirituality, or faith
 Ability limitations, impairments
 Sexual, affectional orientation
 Cisgender, transgender, or otherwise identified
 Age, generation
 Socioeconomic status, affluence, homelessness
 Military upbringing, involvement, deployment
 Criminal justice system, gang culture, drug culture
 Immigration status, language preference
 Geographic influences, environmental factors
 Experiences of oppression or marginalization

Your discussion of Multicultural Considerations should include 3–4 well-formed

paragraphs. In response to the prompts above, begin typing here:

Narrative Summary
Take a step back and, through the lens of your education to this point, work to conceptualize
the big picture. Consider the influence of all the information in Part I. Consider how it has all
culminated and impacted who your student is and their worldview. Within that context,
consider the problem they presented with for counseling and address each of the following
elements:
 Describe your understanding of the problem
 Describe your observations of the student
 Describe your impressions of the student
 Describe any factors contributing to or reinforcing the problem
 Describe the purpose of the student’s behaviors
 Describe themes and patterns that emerge or connect
 Describe barriers to growth and coping
 Describe strengths, assets, protective factors, and signs of resilience

Your discussion of the Narrative Summary should include 3–4 well-formed

paragraphs. In response to the prompts above, begin typing here:

Theoretical Orientation and Application

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Your theoretical orientation influences your counseling approach. While you are likely still in
the very early stages of considering and trying on different theoretical orientations, you have
likely noticed that some seem to resonate with you more than others. While you have been
trained in Person-Centered Theory, consider another orientation that most closely aligns with
your understanding of human behavior and your approach to it. In doing so, respond to the
following:
 State your preferred theoretical orientation and the original theorist
 Describe what elements of this preferred theoretical orientation resonate with you
 Explain how this preferred theoretical orientation approaches student problems
 Explain how this preferred theoretical orientation approaches positive change
 Describe how this preferred theoretical orientation would make sense of your student’s
presenting problem
 Now select another counseling theory and contrast how it would make sense of your
client’s presenting problem differently

Your discussion of Theoretical Orientation should include 3–4 well-formed

paragraphs. In response to the prompts above, begin typing here:

Resources
It is important to recognize the positive impact that supports and resources can have on a
student’s life. You will want to be intentional in identifying and linking the student with
resources to further support and facilitate their growth. With this in mind, address each of the
following elements:
 Describe the resources currently available to and being utilized by the student
 Describe additional resources that would benefit and support the student. Examples
include child protective services, medical doctor referral, peer support, crisis services,
substance abuse referral, academic supports, school nurse, suicide hotline, mental
health referral, and so on.
 Describe how these additional resources might help to stabilize, protect, and facilitate
wellness in the student

Your discussion of Resources should include 3–4 well-formed paragraphs. In response

to the prompts above, begin typing here:

Intervention Planning
The nature of the intervention plan should coincide with the needs of the student. Additionally,
treatment goals should be SMART (specific, measurable, attainable, realistic, and timely). Using
your theoretical foundation of Person-Centered Theory coupled with your preferred theoretical
orientation described in Part II, respond to the following elements:
 Short-term Academic SMART goal for treatment

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  Short-term Person/Social SMART goal for treatment
 Short-term Systemic/Career SMART goal for treatment
 Interventions, approaches, and techniques to work towards these goals
 Long-term Academic SMART goal for treatment
 Long-term Person/Social SMART goal for treatment
 Long-term Systemic/Career SMART goal for treatment
 Interventions, approaches, and techniques to work towards these goals
 How will you involve school personnel in supporting the student?
Your discussion of Intervention Planning should include complete-sentence, bulleted
responses to each of the prompts. In response to the prompts above, begin typing
here:

Ethical and Legal Considerations

Nearly all students and every situation present the possibility for ethical concerns and
dilemmas. It is important to be proactive and intentional in our consideration of what those
might be. Ethical challenges can arise in a number of ways, including
transference/countertransference, court-ordered counseling, informed consent, boundary
violations, poor self-care, limits of confidentiality, and mandated reporting, to name a few.
Using the ACA Code of Ethics, reflect on your work with the student and respond to the
following:
 Describe potential ethical dilemmas present or potentially present
 Identify your own barriers or challenges that may complicate the ethical dilemma
 Explain the steps you should take to be intentional and proactive in your ethical
approach

Your discussion of Ethical and Legal Considerations should include 3–4 well-formed
paragraphs. In response to the prompts above, begin typing here:

Social Change Implications

The end of your work with a student should not be the end of your work. Each student impacts
us as we impact them. Reflect on your student and their circumstances. Consider their efforts in
relation to their successes and failures. Keeping in mind all of the information you have
considered for this case and all of the insight you have gained, respond to the following
elements:
 Address the systems and barriers the student experiences that impacted the current
situation and outcomes
 If changed or removed, identify what systems and barriers could impact positively upon
this individual in the future

© 2024 Walden University, LLC Page 16 of 33

  Discuss how your work with this student has informed your understanding of a larger
social challenge or barrier
 Identify steps you could take to effect positive social change in relation to this social
challenge or barrier

Your discussion of Social Change Implications should include 3–4 well-formed

paragraphs. In response to the prompts above, begin typing here:

© 2024 Walden University, LLC Page 17 of 33

Case Conceptualization Example
Client Information:
 Name: [Client's Full Name]
 DOB: [Date of Birth]
 Gender: [Male/Female/Non-binary]
 Occupation: [Occupation]
 Presenting Concerns: The client reports persistent feelings of sadness, hopelessness,
and a lack of interest in activities they once enjoyed. They have experienced a significant
decline in energy levels, disruptions in sleep patterns, and changes in appetite leading to
weight loss.

Biopsychosocial Assessment:
1. Biological Factors:
o The client's family history reveals a genetic predisposition to mood disorders,
with instances of depression reported among immediate family members.
o Physical health assessment indicates disruptions in sleep patterns and changes in
appetite, suggesting potential neurobiological factors contributing to the
depressive symptoms.
2. Psychological Factors:
o The client exhibits negative thought patterns, such as pervasive feelings of
worthlessness and self-blame. Automatic thoughts are characterized by a
pessimistic outlook on the future.
o Past traumas and unresolved issues contribute to a negative self-concept,
affecting the client's overall sense of well-being.
3. Social Factors:
o The client reports strained interpersonal relationships, particularly in their family
and social circles. Limited social support exacerbates feelings of isolation and
contributes to the maintenance of depressive symptoms.
o Work-related stressors, including increased workload and reduced job
satisfaction, impact the client's overall functioning and contribute to the
development and perpetuation of depressive symptoms.

Cognitive-Behavioral Formulation:
The client's depressive symptoms are maintained by a combination of cognitive distortions and
behavioral patterns. Negative automatic thoughts, such as self-critical beliefs and catastrophic
thinking, contribute to a pervasive sense of hopelessness. The client engages in avoidance
behaviors, withdrawing from social activities and neglecting self-care, further reinforcing the
negative cycle.

Treatment Goals:
1. Cognitive Restructuring:
o Challenge and reframe negative automatic thoughts to promote more adaptive
thinking patterns.

© 2024 Walden University, LLC Page 18 of 33

 o Develop and implement cognitive-behavioral strategies to address distorted
thinking and promote self-compassion.
2. Behavioral Activation:
o Encourage the client to gradually re-engage in pleasurable activities and social
interactions to counteract avoidance behaviors.
o Establish a structured daily routine to improve sleep hygiene and energy levels.
3. Interpersonal Skills Building:
o Explore and address underlying interpersonal conflicts contributing to strained
relationships.
o Enhance communication skills to improve the quality of social interactions and
build a support system.
4. Mindfulness and Self-Compassion:
o Introduce mindfulness techniques to help the client develop awareness of
negative thought patterns and cultivate a non-judgmental attitude.
o Foster self-compassion to counteract self-critical beliefs and enhance emotional
resilience.

Interventions:
1. Cognitive Restructuring Exercises:
o Implement thought records and guided self-reflection to identify and challenge
negative automatic thoughts.
2. Behavioral Activation:
o Collaboratively develop a list of pleasurable activities and establish a schedule to
gradually reintroduce enjoyable experiences into the client's life.
3. Interpersonal Skills Training:
o Role-play effective communication strategies and explore assertiveness training
to address interpersonal conflicts.
4. Mindfulness and Relaxation Techniques:
o Introduce mindfulness meditation and deep-breathing exercises to enhance
emotional regulation and reduce stress.

Measurement and Evaluation:

Utilize standardized assessment tools such as the Beck Depression Inventory (BDI) or Patient
Health Questionnaire-9 (PHQ-9) to monitor changes in depressive symptoms over time.
Regularly reassess treatment goals and modify interventions based on the client's progress and
feedback.

Prognosis:
With targeted interventions addressing cognitive, behavioral, and interpersonal factors, the
prognosis for improvement in the client's depressive symptoms is good as evidenced by past
completed outpatient treatment, maintenance of symptoms for 6 years prior to return for
services, expressed motivation to achieve goals. Regular monitoring and adjustments to the
treatment plan will be essential to ensure sustained progress.

© 2024 Walden University, LLC Page 19 of 33

Signature: [Therapist's Full Name, Credentials]

© 2024 Walden University, LLC Page 20 of 33

 Forms
Abuse and/or Neglect Form Example

© 2024 Walden University, LLC Page 21 of 33

Adapted Triage Assessment Form (TAF) Template
Client Name: ____________________________________________ Time/Date: __________________
Crisis Worker: _________________________ Contact Type: __________ Phone: _______ Office: _______
Field
Crisis Event: ____________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Disposition: ____________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Observations (Check as many that apply)

___ off medication* ___ oppositional defiant to verbal ___ uncooperative

suggestions
___ medication not effective*** ___ flat affect
___ coercion/intimidation
___ hallucinating*** (___smells___ ___ impulsivity
sights___sounds___touch) ___ aggressive gestures*
___ hysterical
___ bizarre behavior/appearance ___ reckless behavior
___ confusion
___ poor hygiene ___ self-injurious behavior
___ unable to follow simple
___ absurd, illogical speech*** ___ physically violent* directions

___ paranoid/suspicious thoughts*** ___ verbal threats to self or others ___ unable to control emotions

___ flashbacks, loss of reality contact ___ suicidal/homicidal ___ cannot recall personal
thinking/verbalizing information (phone,
___ intoxicated/drugged*
address)
___ suicidal/homicidal
___ under the influence of mood-altering
gestures/behaviors* ___ situation perceived as
substance
unreal (spectator)
___ suicidal/homicidal plan clear*
___ other (explain)
___ nonresponsive***
Notes:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________

*** psychiatric evaluation recommended * hold for law enforcement officers or EMTs

© 2024 Walden University, LLC Page 22 of 33

 SEVERITY SCALES (Check those that apply)
1 2/3 4/5 6/7 8/9 10
No Minimal Low Moderate Marked Severe
Impairment Impairment Impairment Impairment Impairment Impairment
A  Stable mood,  Affect elevated but  Evidence of  Feelings are  Feelings are  Feelings are
control of generally negative feelings primarily negative negative and extremely
F feelings. appropriate. pronounced and and are exaggerated highly volatile or pronounced to
increasingly or increasingly may be being devoid of
F inappropriate. diminished. nonexistent. feeling.
 Feelings are  Brief periods of  Duration of feeling  Efforts to control  Extremely  No ability to
E appropriate. slightly elevated intensity longer emotions are not limited control control feelings
negative mood. than situation always successful. of emotions. regardless of
C warrants. potential danger to
self or others.
T  Emotions are  Emotions are  Emotions are  Emotions not under  Emotions start  Emotions of the
under substantially under controlled but control but remain to generalize crisis are
I control. control. focused on crisis focused on crisis. from crisis event generalized to
event. to other people other people and
V and situations. situations.
 Responses  Responses to  Responses to  Responses to  Responses to  Cannot respond to
E to questions/ questions/ questions/ questions/ questions/ questions/
requests are requests are requests vary from requests are requests requests because
calm and emotional but rapid and agitated emotionally volatile noncompliant of interference of
composed. composed. to slow and or beginning to shut due to emotions.
subdued. down. interference of
emotions.
B  Behaviors  Behaviors are  Behaviors are  Behaviors are  Behaviors are  Behaviors are
are socially mostly effective; somewhat maladaptive but not likely to totally ineffective
E appropriate. outbursts, if ineffective yet not immediately intensify crisis and accelerate the
present, are dangerous. destructive. situation. crisis.
H inconsequential.
A  Daily  Can perform tasks  Performance of  Performance of tasks  Ability to  Unable to perform
functioning is needed for daily tasks needed for needed for daily perform tasks even simple tasks
V unimpeded. functioning with daily living is living is noticeably needed for daily needed for daily
minimal effort. minimally compromised. functioning is functioning.
I compromised. seriously
impaired.
O  Threat or  Behavior  Behaviors are a  Behavior is a  Impulsivity has  Behaviors are
R danger is demonstrates minimal threat to potential threat to the potential to highly destructive
nonexistent. frustration but is self or others. self or others. be harmful to and could possibly
S nonthreatening. self or others. cause injury/death
to self or others.

 Behavior is  Behaviors mostly  Behavior is  Upon request,  Behaviors are  Behavior is out of
stable and stable and becoming unstable behaviors can be very difficult to control and
non-offensive. non-offensive. and offensive. controlled with control, even nonresponsive to
effort. with repeated requests.
requests.
C  Decisions are  Decisions may not  Decisions are  Decisions are  Decisions have  Decisions are a
considerate be considerate of inconsiderate of offensive and the potential to clear and present
O of others. others. others. antagonistic of be harmful to danger to self and
G others. self or others. others.
N  Decisions are  Decisions are  Decisions are  Decisions about  Decisions are  Decision making is
logical and becoming becoming illogical, crisis are beginning illogical and frenetic or frozen
I reasonable. indecisive but only unreasonable, and to interfere with have little basis and not based in
with respect to generalized beyond general functioning. in reality, and reality and shuts
T crisis. crisis. general down general
functioning is functioning.
V compromised.
 Perception of  Thinking is  Thinking is focused  Thoughts are limited  Thoughts about  Thoughts are
E crisis event influenced by crisis on crisis but is not to crisis situation crisis have chaotic and
substantially but is under all consuming. and are becoming all become completely
matches control. consuming. pervasive. controlled by crisis.
reality.
 Able to carry  Able to carry on  Ability to carry on  Responses to  Is defiant to  Requests and

© 2024 Walden University, LLC Page 23 of 33

 on reasonable dialog reasonable dialog questions and requests and questions are
reasonable and understand restricted and has requests are questions believed as threats
dialog and and acknowledge problems restricted or and/or and responded to
understand views of others. understanding and inappropriate and inappropriate aggressively.
and acknowledging denies with and
acknowledge views of others. understanding views antagonistic of
views of of others. others.
others.
 Problem  Problem solving is  Problem solving is  Problem solving is  Problem solving  Problem solving is
solving is minimally limited. blocked. ability is absent. not observable
intact. compromised. with no ability to
concentrate.
CRISIS EVENT
Identify and describe briefly the crisis situation:______________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

AFFECTIVE DOMAIN
Identify and describe briefly the affect that is present.
(If more than one affect is experienced, rate with #1 being primary, #2 secondary, #3 tertiary.)
ANGER/HOSTILITY: _____________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

ANXIETY/FEAR: ________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

SADNESS/MELANCHOLY: ________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

FRUSTRATION: ________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

BEHAVIORAL DOMAIN
Identify and describe briefly which behavior is currently being used.
(If more than one behavior is utilized, rate with #1 being primary, #2 secondary, #3 tertiary.)
APPROACH:___________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

© 2024 Walden University, LLC Page 24 of 33

AVOIDANCE: __________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

IMMOBILITY: _________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

COGNITIVE DOMAIN
Identify if a transgression, threat, or loss has occurred in the following areas and describe briefly.
(If more than one cognitive response occurs, rate with #1 being primary, #2 secondary, #3 tertiary.)
PHYSICAL (food, water, safety, shelter, etc.): ________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Transgression_____ Threat_____ Loss______

PSYCHOLOGICAL (self-concept, sense of emotional well-being, ego integrity, self-identity, etc.): _______________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Transgression_____ Threat______ Loss______

SOCIAL RELATIONSHIPS (positive interaction and support, family, friends, coworkers, church, clubs, etc.): _______________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Transgression______ Threat______ Loss______

MORAL/SPIRITUAL (personal integrity, values, belief system, spiritual reconciliation): _______________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

TRIAGE ASSESSMENT (X = Initial Assessment/O = Terminal Assessment)

Affective Behavioral
___ Anger ___ Fear ___ Sadness ___ Approach ___ Avoidance ___ Immobile
   
1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10

Cognitive
___ Transgression ___Threat ___Loss
 
1 2 3 4 5 6 7 8 9 10
______ Physical _______ Psychological _______ Relationship _______ Moral/Spiritual

© 2024 Walden University, LLC Page 25 of 33

 Initial Total Score: _________ Terminal Total Score: _________ (if used)

Transgression______ Threat______ Loss______

Describe the observations that led you to check the characteristics above:
______________________________________________________________________________________
______________________________________________________________________________________

© 2024 Walden University, LLC Page 26 of 33

 Treatment Plans

Books in Walden Library with Examples of Many Treatment Plans

Berghuis, D. J., Bogue, B., & Nandi, A. (2015). The probation and parole treatment planner with
DSM-5 updates. John Wiley & Sons, Inc.
Berghuis, D. J., Jongsma, A. E., & Bruce, T. (2015). The severe and persistent mental illness
treatment planner with DSM-5 updates (2nd ed.). John Wiley & Sons, Inc.
Berghuis, D. J., Jongsma, A. E., & Slaggert, K. H. (2012). The intellectual and developmental
disability treatment planner with DSM-5 updates (2nd ed.). John Wiley & Sons, Inc.
Berghuis, D. J., & Klott, J. (2015a). The suicide and homicide risk assessment and prevention
treatment planner with DSM-5 updates (2nd ed.). John Wiley & Sons, Inc.
Berghuis, D. J., & Klott, J. (2015b). The co-occurring disorders treatment planner with DSM-5
updates (4th ed.). John Wiley & Sons, Inc.
Berghuis, D. J., Peterson, L. M., McInnis, W. P., & Bruce, T. J. (2014b). The adolescent
psychotherapy treatment planner (5th ed.). John Wiley & Sons, Inc.
Frazer, D. W., Hinrichsen, G. A., & Berghuis, D. J. (2015). The older adult psychotherapy
treatment planner with DSM-5 updates (3rd ed.). John Wiley & Sons, Inc.
Jongsma, A. E., Peterson, L. M., & Bruce, T. J. (2021). The complete adult psychotherapy
treatment planner (6th ed.). John Wiley & Sons, Inc.
Knapp, S. E., Berghuis, D. J., & Dimmitt, C. L. (2014). The school counseling and school social
work treatment planner with DSM-5 updates (2nd ed.). John Wiley & Sons, Inc.
Kolski, T. D., Berghuis, D. J., & Myer, R. A. (2014). The crisis counseling and traumatic events
treatment planner, with DSM-5 updates (2nd ed.). John Wiley & Sons, Inc.
O’Leary, K. D., Heyman, R. E., & Berghuis, D. J., (2014). The couples psychotherapy treatment
planner with DSM-5 updates (2nd ed.). John Wiley & Sons, Inc.
Perkinson, R. R., Berghuis, D. J., & Bruce, T. (2014). The addiction treatment planner; Includes
DSM-5 updates (5th ed.). John Wiley & Sons, Inc.

© 2024 Walden University, LLC Page 27 of 33

 Progress/Case Notes
Books in Walden Library with Examples of Progress/Case Note Plans

Berghuis, D. J., & Jongsma, A. E. (2014). The adult psychotherapy progress notes planner (5th

ed.). John Wiley & Sons, Inc.

Berghuis, D. J., Peterson, L. M., McInnis, W. P., & Bruce, T. J. (2014a). The child psychotherapy

treatment planner (5th ed.). John Wiley & Sons, Inc.

Berghuis, D. J., Peterson, M., McInnis, W. P., & Jongsma, A. E. (2014). Child psychotherapy

progress notes planner (5th ed.). John Wiley & Sons, Inc.

Jongsma, A. E., & Berghuis, D. J. (2015). The addiction progress notes planner (5th ed.). John

Wiley and Sons, Inc.

© 2024 Walden University, LLC Page 28 of 33

BIRP Note Example
Date: [Date]
Client Name: [Client's Full Name]
DOB: [Date of Birth]
Session Number: [#]
Therapist: [Therapist's Full Name]

Behavior: [Describe the client's observable behaviors during the session. This may include
verbal and non-verbal actions. For example: "Client presented with a sad affect, limited eye
contact, and slouched posture. They reported low energy and a lack of motivation to engage in
daily activities."]

Intervention: [Outline the therapeutic interventions implemented during the session. This can
include specific techniques, strategies, or tools used to address the client's concerns. Use
caution that theoretical orientation is not a treatment intervention. Counselors often misuse
theory as intervention (e.g., CBT to teach...). Empirically supported interventions need to be
used to address the diagnosis/symptoms regardless of theoretical orientation of counselor. For
example: "Used cognitive restructuring techniques to challenge automatic negative thoughts.
Introduced a mood tracking journal and discussed the importance of identifying and challenging
negative thought patterns."]

Response: [Document the client's response to the interventions and their overall engagement
in the therapeutic process. A rule of thumb is that for each intervention used, there should be a
corresponding response that offers evidence. For example: " The client responded well to the
cognitive restructuring exercises, showing increased awareness of negative thought patterns
(e.g., "I noticed that I always start out looking at the worst"). They expressed initial skepticism
(e.g., "I want to try but I am not sure it will work), but later acknowledged the potential benefits
of monitoring and challenging their thoughts (e.g., "I am surprised that I actually made myself
think more positively"]

Plan: [Outline the plan for ongoing treatment and any recommendations for future sessions.
This may include goals, homework assignments, or referrals. For example: "Plan to continue
exploring and challenging negative thought patterns in future sessions. Discussed the possibility
of a psychiatric evaluation for medication management and provided the client with a mood
tracking worksheet to complete daily before the next session."]

Signature: [Therapist's Full Name, Credentials]

© 2024 Walden University, LLC Page 29 of 33

DAP Note Example
Date: [Date]
Client Name: [Client's Full Name]
DOB: [Date of Birth]
Session Number: [#]
Therapist: [Therapist's Full Name]

Data: [Detail observable and measurable information. Include any relevant behavioral
observations, such as changes in sleep, appetite, and energy levels. For example: "Client reports
feeling overwhelmed with sadness and a lack of energy. They describe a persistent sense of
hopelessness and difficulty finding pleasure in activities they once enjoyed. Client appears
fatigued, with noticeable difficulty keeping their eyes open in session —reporting difficulty
falling asleep and waking up multiple times during the night. They report having experienced a
noticeable decrease in appetite and weight loss since the last session"]

Assessment: [Include your clinical impressions and analysis of the client's current mental health
status. For example: "The client's presentation is consistent with symptoms of major depressive
disorder. The persistent low mood, feelings of hopelessness, changes in sleep and appetite, and
decreased interest in previously enjoyed activities are indicative of a moderate to severe
depressive episode."]

Plan:
1. Safety Assessment: [Assess and address any immediate safety concerns, such as suicidal
thoughts or self-harm. If there are any safety concerns, outline the steps taken to
ensure the client's safety.]
2. Therapeutic Interventions: [Discuss the therapeutic interventions employed during the
session and plan for ongoing treatment. This may include specific therapeutic
modalities, coping strategies, and homework assignments.]
3. Medication Review: [If applicable, discuss any changes in medication or potential
referrals to a psychiatrist for medication evaluation. Collaborate with any other
healthcare professionals involved in the client's care.]
4. Follow-Up: [Set a date for the next session and discuss any specific goals or tasks for the
client to work on before the next appointment. Consider involving the client in setting
these goals to enhance engagement and motivation.]

Signature: [Therapist's Full Name, Credentials]

© 2024 Walden University, LLC Page 30 of 33

SOAP Note - CMHC Example
Date: [Date]
Client Name: [Client's Full Name]
DOB: [Date of Birth]
Session Number: [#]
Therapist: [Therapist's Full Name]

Subjective: [Summarize the client's subjective experience during the session. Include information about
the client's mood, affect, thoughts, and feelings. For example: "Client reports feeling overwhelmed with
sadness and a lack of energy. They describe a persistent sense of hopelessness and difficulty finding
pleasure in activities they once enjoyed."]

Objective: [Detail observable and measurable information. Include any relevant behavioral
observations, such as changes in sleep, appetite, and energy levels. For example: "Client appears
fatigued, with noticeable difficulty keeping their eyes open in session —reporting difficulty falling asleep
and waking up multiple times during the night. They have experienced a noticeable decrease in appetite
and weight loss since the last session."]

Assessment: [Include your clinical impressions and analysis of the client's current mental health status.
For example: "The client's presentation is consistent with symptoms of major depressive disorder. The
persistent low mood, feelings of hopelessness, changes in sleep and appetite, and decreased interest in
previously enjoyed activities are indicative of a moderate to severe depressive episode."]

Plan:
5. Safety Assessment: [Assess and address any immediate safety concerns, such as suicidal
thoughts or self-harm. If there are any safety concerns, outline the steps taken to ensure the
client's safety.]
6. Therapeutic Interventions: [Discuss the therapeutic interventions employed during the session
and plan for ongoing treatment. This may include specific therapeutic modalities, coping
strategies, and homework assignments. Use caution that theoretical orientation is not a
treatment intervention. Counselors often misuse theory as intervention (e.g., CBT to teach...).
Empirically supported interventions need to be used to address the diagnosis/symptoms
regardless of theoretical orientation of counselor.]
7. Medication Review: [If applicable, discuss any changes in medication or potential referrals to a
psychiatrist for medication evaluation. Collaborate with any other healthcare professionals
involved in the client's care.]
8. Follow-Up: [Set a date for the next session and discuss any specific goals or tasks for the client
to work on before the next appointment. Consider involving the client in setting these goals to
enhance engagement and motivation.]

Signature: [Therapist's Full Name, Credentials]

© 2024 Walden University, LLC Page 31 of 33

SOAP Note – SC Example

Subjective: Summarize what the student says about his/her feelings, thoughts, actions, concerns,
progress in treatment, and anything else pertinent to his/her treatment goals. How does the student
describe his/her problem? This is usually a short quote or statement from the student describing their
subjective description of the problem. No counselor interpretation of student statements is entered in
this section of the SOAP note.

For example: Student stated, "I just can't please my parents no matter what I do." Student reports that
his parents constantly yell at him and put him down. He stated his mother was “fussing” at him on the
way to counseling since he failed his test. He continues to reiterate his level of stress at home given his
parents constant fighting. He wishes his parents would get a divorce, so he can have peace at home. The
student changed the subject when asked by the counselor about anger towards her father. Student
denied any suicidal ideation.

Objective: Detail observable and measurable information. These are written as factual notations. Verbal
and nonverbal, including eye contact, voice tone and volume, body posture. Especially note any
changes and when they occur. Note discrepancies in behavior. It is helpful to discuss manner of dress,
physical appearance, illnesses, disabilities, energy level, general self-presentation.

For example: Student was tearful at times; gazed down and fidgeted with his shirt buttons. During the
session, the student appeared to be distracted and responded in short agitated statements. He raised his
voice when discussing parental expectations. Student was dressed casually. Hygiene was unoteworthy.

Assessment: Include your interpretation, tentative hypotheses, or hunches about the meaning and
significance of student statements and counselor observations.

For example: “Student is angry with his parents and is apprehensive about how to change things at
home. He is beginning to express his anger and resentment towards his parents, especially as related to
their expectations. The student is often triangulated by his parents and often forced to take sides.
Student seems to be discouraged about his home life and feels helpless to change anything. Student
appears to be moderately depressed as evidenced by social withdrawal, increase agitation and
aggression, and drop in grades.”

Plan: The counselor's plan for future treatment sessions. The plan is based upon what the student said,
what the counselor observed, and the counselor's assessment of what was said and observed. Include
date of next appointment.

For example: Continue to process students' anger and recognize anger triggers; complete emotion
regulation worksheet (model for describing emotions); Continue to monitor suicidal ideation.

© 2024 Walden University, LLC Page 32 of 33

 Treatment Summary/ Discharge
Elements most commonly included:

1. Date of admission
2. Date of discharge
3. Date of last contact
4. Diagnostic criteria at admission (this is the golden thread from the diagnostic
assessment)
5. Diagnostic criteria at discharge (this is the golden thread from the progress reflected in
the progress/case notes)
6. Level of care and services provided during treatment
7. Client’s response to treatment
a. include progress in meeting treatment goals and condition at discharge (this is
the golden thread from the progress reflected in the progress/case notes)
8. Recommendations and/or referrals for additional treatment or other services, and after
care options.
9. Reasons for termination:
a. Reached treatment goals
b. No longer benefiting from service
c. Referred to another agency or level of care
d. Client discontinued services or involuntarily terminated

© 2024 Walden University, LLC Page 33 of 33