TP/TPR

TP/TPR
The Mahogany Project
Contract
Participant ID
Participant's Name
First NameLast Name
Counselor/Therapist:
Session Type:
Date of Service:
MonthDayYear
Date
Location
Start Time
:HourMinutesAM/PM Option
End Time
:HourMinutesAM/PM Option
Duration
Working Diagnosis
Problem 1:
Problem 1:
Long Term Goal #1
Long Term Goal #1:
Stage of Change:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Date Initiated/Continued
MonthDayYear
Date
Was Treatment Goal Extentded? Why?
Target Date of Completion
MonthDayYear
Date
Problem 2:
Problem 2:
Long Term Goal #2
Long Term Goal #2:
Stage of Change:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Date Initiated/Continued
MonthDayYear
Date
Was Treatment Goal Extentded? Why?
Target Date of Completion
MonthDayYear
Date
Problem 3:
Problem 3:
Long Term Goal #3
Long Term Goal #3:
Stage of Change:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Short Term Objectives:
Date Initiated/Continued
MonthDayYear
Date
Was Treatment Goal Extentded? Why?
Target Date of Completion
MonthDayYear
Date
Problem: Client Will Need an Aftercare Plan
Long Term Goal: Client and Counselor/Therapist will develop an aftercare plan.
State of Change: Precontemplation
1. Client will identify 3 relapse issues and 3 corresponding interventions to address relapse issues. Client will review learned coping skills and insights made during therapy, complete post assessments, and complete discharge paperwork in 4 sessions.
2. Client and Counselor/Therapist will identify 2 current services in place for the client and family and 3 needed services for the client and family.
3. Counselor/Therapistwill facilitate linkage to identified needed services.
Date Initiated/Continued
MonthDayYear
Date
Was Treatment Goal Extentded? Why?
Target Date of Completion
MonthDayYear
Date
Participant
First Name Last Name Signature
Counselor/Therapist
Doudrige Meme Dorcin
Signature Date
Supervisor
Karen Edouard
Signature Date
Should be Empty:

TP/TPR

Participant

Counselor/Therapist

Supervisor