(title) Weekly Client Review--(Name of Intern)

(date) week of:  11/1/99

 

Client Name and age              [include all active clients]

   # sessions      to date

 * client risk level  * difficulty level * "stuckness" level   Fee/ Source

name (age)

# completed

risk for suicide, abuse, relapse

complexity, resistance, etc

intern's self evaluation

 amount and/ or payor
"

"

"

"

"

-
" " " " " -

* ratings are on a scale of 1 to 5, with 5 the highest level...

Client Name--Session Date--Session Number 

D:   = description, as in SOAP notes...D combines the "S" and the "O"

  • subjective report of client and therapists observations of the client.  Useful to include direct quotes or phrases.

  • how client feels, important life events, situations, developments

  • actions/interactions in session

A:  = assessment.  Therapist can include in assessment:

  • subjective and objective material gathered in the session

  • information relating to formulation or testing of hypothesis

  • diagnostic material/information (can be formalized as 5 axis, provisional, et cetera)

  • issues relating to theory (e.g., developmental issues, stages)

  • ongoing assessment in light of new information 

P:  = therapy plan.  Discusses:

Plans and goals based upon intake and initial assessment, criteria for success (how you'll know you've met goals)

modifications during the therapy process as growth takes place, hypothesis changes, new issues come to light

interventions used in current session

plans for future interventions

changes in goals, treatment plan

 

 

As supervisor becomes familiar with clients, intern's skills and style, paragraphs D, A, and P may become more brief and succinct. 

return to supervision form example

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