ACCT has downloadable forms for you to customize HERE. I have several other suggestions for your use below.

Informed Consent

1. Here is an Informed consent form by the Therapist Private Practice Blog.

2. Here is a Word Doc that you can download to make your own.

The intake process is vital to the formation of any counselling relationship. Given the fact that the intake process is the foundation upon which the structure of the therapeutic relationship is built, there are some important considerations counsellors need to keep in mind. See HERE for the full article.

Also, read Tips for Navigating Intake Sessions.

Following are some other examples of various forms that you will need in your counselling practice. 

How to Write a Collaborative Treatment Plan

Counselling treatment plans are blueprints for constructing the changes the client wishes to make. The counsellor is not solely responsible for developing the client's plan.

Most treatment plans that respect the client’s rights to self-determination and informed consent are the result of a collaborative effort between the client and the counsellor.

The counsellor’s primary responsibility is to provide feedback that evokes the client's workable problems, long-term goals and short-term objectives, as well as necessary therapeutic interventions.

From Assessment to Objectives

An effective treatment plan begins with an accurate assessment. The client then determines which problem to address first. With the assistance of the counselor, the client selects a long-term goal of change for this problem. For example; if the problem is feeling depressed every day, the goal might be to experience depression only 2 out of 7 days. This process is repeated until objectives are determined for each problem.

Making Objectives Manageable

Objectives are broken into short-term goals. The number of short-term goals per objective varies, primarily because they are based on the unique resources, skills and abilities of the client. For example; if the objective is to reduce days of depression to 2 per week, the client may decide to eliminate unresolved guilt and pessimistic thinking patterns, and then identify motivations for change. Each short-term objective is matched with a therapeutic intervention from the counselor. This may include the use of motivational interviewing to help resolve guilt, cognitive restructuring to change pessimistic thinking, and value clarification to identify motivations for change.  

Create a Treatment Plan by Discussing Goals

Heather Strong, Ph.D.

Motivation is the driving force that makes us want to achieve our goals in life. One of the tools that we can use to turn our motivations into action is by developing a SMART goal. SMART goals are effective because they help you think through the details of what you are going to do so that you can put them into practice.

SMART goals are defined as Specific, Measurable, Attainable, Realistic and Time-sensitive plans of action. Here is an explanation of what each component of the SMART goal is, with an example, and then at the end there is a worksheet that will help you develop your own SMART goal.

#1. Goals should be specific. They should be clear and emphasize what you want to happen. Specifics help us to focus and define what we are going to do. Ensure the goals you set are very specific, clear and easy.

Here we describe the What, Why, and How of the SMART model.

WHAT are you going to do? Use action words

WHY is this important to do at this time?

HOW are you going to do it? (By planning what, when, where, and how)

Example: Instead of setting a goal to “exercise to be healthier” set a specific goal such as:

What? To participate in a 5km walk for breast cancer in 1 year.

Why? To be healthier and take care of my body.

How? To walk 30 minutes around my neighbourhood three days a week and join a walking group.

#2. Goals should be measurable. Choose a goal where you can measure its progress. This will help you identify when the changes take place. When you measure your progress, you stay on track, reach your target dates, and experience the excitement of achievement that feeds your motivation to continue.

Example: How will you measure your goal? Through time, distance and number of days I exercised this week. I will use an exercise log sheet where I record the exercise I did, how much time I spent doing the exercise, the distance I went and how I felt about doing the exercise after it was done.

#3. Goals should be attainable. A goal needs to be something that will stretch you slightly so you feel you can do it and it will demand a real commitment from you. Goals you set which are too big or too hard, you probably won’t commit to doing in the long run. After all we all start with the best of intentions, but if your goal feels overwhelming and too large you’ll be more likely to give up before you achieve it.

Example: A goal that is too large: To exercise 7 days this week for 2 hours each day. A goal that is just right: To exercise 3 times this week for 30 minutes.

#4. Goals should be realistic. This doesn’t mean easy but it does mean that you should feel capable in achieving this goal. It means that you have the skills and resources available to do the work. The goal needs to be realistic for you and where you are at the moment.

Example: A goal of exercising every single day when you have not exercised regularly in over ten years may not be realistic.

It may be more realistic to set a goal of exercising 3 days a week for 3 10-minute bouts over the course of the day. Then choose to work towards exercising 3 days a week for 30-minutes straight gradually as and when this feels realistic for you.

#5. Goals should be time-sensitive. Set a timeframe for the goal: for next week, in one month, three months, 6 months and one year. Putting an end point on your goal gives you a clear target to work towards.

If you don’t set a time, the commitment is too vague. It tends not to happen because you feel you can start at any time. Without a time limit, there’s no urgency to start taking action now.

Example: My long-term goal is to participate in a 5-km walk for breast cancer in 1 year. I will do a practice walk (not timed in 6 months with my walking group).

Extra questions to ask yourself when setting goals:

Does this goal involve changing things about YOU (not changing other people)

Does this goal involve changing things that are within your control?

Will this goal make an immediate improvement in your life?

Is there another goal you need to reach first before you can accomplish this goal?

Why is this goal important to you?

What would success in achieving this goal look like?

References: Information adapted from Mind Over Mood by Padesky & Greenberger (1995); 

1. Client’s name: 

2. Date of session:

3. Opening Question: Record the answer to your opening question in this section. Questions might include: “How are you?,” “Are there any new major updates since our last session?,” and “If your life was a newspaper right now, what would be on the front page?”

4. Significant Observations: Make observations about how your client looks or are carrying themselves (i.e., sleepy, disheveled, rested, happy, depressed, scattered, angry, etc.).

5. Review of the Homework: If there was homework given in the previous session, take brief notes about whether it was completed and how it went. If the assignment was not completed, ask several questions to see why and note those here. 

6. Prep for the session: This is the only part filled out before the session. It note the things you think should be covered from last time and any specific goals you may have for the session. In solution-based counselling it can be important to have some thoughts prepared before the session begins, but hold the goals loosely. 

7. Flow of the session: Take notes as the session flows; outline  the conversation. As a rule of thumb, there should be something on the page for every 10 minutes of the session. Note turns in conversation as section titles with bullets underneath.

8. Main Issue for the Session: Aim to identify the main problem for the session by the end of the first page. This helps you understand what you and your client are trying to solve. The session issue may be related to the overall issue you are working on together, or it may be a new issue. It can be helpful, as I am looking back over all of your notes, to quickly see what you and your client have considered primarily in each session. 

9. Substance abuse: This is a simple “Yes” or “No” if your client is using a substance as a coping mechanism. 

10. Current Danger Potential: “SI” is for Suicidal Ideation; “HI” is for Homicidal Ideation; The other two—harming self or harming other—is for any thought of harm that is not death related. Write “Other” if there seems to be danger potential. 

11. Next Action and Homework: List any next actions that you will take, or that your client will make, related to the session conversation. Recored any homework assigned. 

12. Phone call between sessions?: If you plan on making contact in between sessions, list it here. In order to jog your memory, you may write specifically why you think additional contact is necessary. 

13. Insight or supervisor consult needed?: If you are stuck on something and need to bring it up with your supervisor, list it here. It is reminder to follow up, and the reason is listed. 

14. Next Appointment Signature: Sign when the notes are done and complete; this serves as a witness to all that is enclosed. My signature is a sign of a satisfactory job and an acknowledgment of truthfulness.

15. End time: Listing when the session ends shows the length of the session and whether you ended on time. 

Adapted from http://www.joshweidmann.com/counseling-notes-template/

Download the adapted Progress Note Template here: