Selecting an Evidence-Based Change Strategy Document This document will include five major sections. Each section is detailed below: Also attached are documents needed to use and reference to complete
Contract and Goal Plan
Temple University School of Social Work
SSWG 5107 Fall 2019
Worker Name: _____________________________________
Client Name: _____Harris Family_________________________________
Date of Initial Intake: ______10/28/19______________________________________
Date of Treatment Plan: ___10/30/19______________________________________
Day/time/place of sessions: ___Mondays at 7p, via video chat___________________
Anticipated # of sessions: ___5_________________________________________
Anticipated method of payment: ___UPMC Insurance___________________
TREATMENT PLAN:
GOAL 1: Each individual will rate their subjective satisfaction with family communication levels at 75% greater than initial score (i.e. if John Jr rated initial at 4/10, then final rating would be at least 7/10) by 12/1/19.
□Objective 1: The family will eat at least two meals a week together, ongoing through 12/1/19.
□Objective 2: Meet once a week for a minimum of 30 minutes without electronics to talk through disagreements and develop a turn-taking rule used in the meetings, so that all family members have a chance to share and feel heard, through 12/1/19.
□Objective 3: When in a disagreement, family members will write their grievances via DBT writing techniques to bring to therapy. Written reflections will be shared at weekly family sessions, through 12/1/19.
□GOAL 2: Daughters will have a move-out plan in place by 12/1/19.
□Objective 1: Daughters will bring a list of at least five apartments within their budget each week at each session, ongoing through 12/1/19.
□Objective 2: Determine roommate situation (i.e. decide if sisters will live together or post on roommate finding website a week until roommate is found) by 12/1/19.
□Objective 3: Save at least two months’ worth of rent together (or one month per daughter) by 12/1/19
I, (client name)__________________________________________________, have been an active participant in the drafting of my Treatment Plan, Goals and Objectives with Social Worker, __________________________________________________________,
□I understand that I am a voluntary participant in the prescribed treatment plan and that this is a living document that can be altered to better fit my needs.
□I understand that, as a client, it is my responsibility to make and keep all appointments and to provide 24 hours notice of need to cancel any appointment.
□If, at any time, I feel that treatment plan is not helpful or not meeting my needs, I will bring this to my social workers attention immediately.
□I have been given a copy of The Patient’s Bill of Rights.
□I understand that all of my communication with my social worker is to be kept confidential unless I express plans to hurt myself or another. I further understand that my social worker is a MSW student and that she is under the supervision of Laurie Friedman, therefore requiring communication regarding my case.
□By signing this document, you are agreeing to the aforementioned terms and conditions of treatment.
Client Name (Please Print)__________________________________________________
Client Signature:__________________________________________________________
Date of Signature:_________________________________________________________
Date of Anticipated Termination of Services:___12/1/19_______
Social Worker Name (Please Print)___________
Social Worker Signature:___________________________________________________
Date of Signature:_____10/30/19________________________________
Supervisor Signature:______________________________________________________
Date of Supervisory Review:________________________________________________
