Date: Client (s): ORS: SEX: SCHOOL/WORK: LIVING WITH: DATE OF INTAKE: Pre-session:

Clinical Notes Counselling Counsellor: SRS: DATE OF BIRTH: REFERRED BY: SUBSTANCE: SESSION: 1 PLANNING SESSION

Presenting Problem: Age of first use of primary drug: Last used / Amount / Context: Current pattern of use: Other drugs: Suicide risk: Relevant Past History: Family Constellation / Living arrangement: Guardians/Familys history of substance use Other conditions / Concurrent disorders Medication Prior counselling / mental health professional experience Professionals involved / Groups attended / Other programs Life Tasks Current Status & Goals: Status School/Work Social/Family Significant other Self Spiritual Goals for presenting problem: The Question: If I did not have this current problem, I would _____________________

Goals

Strengths: Fun/Awesome:

Hero: Others:

Check out: What stood out for client? SRS comment? Clients Plan: Clinical Impressions & Recommendations: Current stressors: Possible function of use: Recommendations for client: Session presentation: Awareness: Self-regulation/emotions: SRS-relationship: Treatment Plan:

Signature and Certification: ______________________________,