A working collaberation between client and therapist is the ideal.
The client/therapist relationship maintains professional boundaries and confidentiality.
The therapist shows client SOAP note taking procedure.
The therapist asks for clients consent to use the format shown.
Client assists with information input.
Client understands treatment plan(s).
Client understands modality options.
Client has clearly stated achievable functional goals within specified/reasonable time frame.
Example 1: If you are a
“_____(profession)____”
and you need to be able to
“______(activity)_____”
each
“______(time)_____”
without
“______(symptom)_____”
both
_______(parties)_____
need to be able to
_______(assess the treatment plan offered)___________
as it applies to the activities of daily living (ADL’s) and
___________(co create short & long term goals)_______
or
__________(offer referral)___________
By frequent short term co-assessments, both parties can quickly determine if the treatment offered is helpful at best, neutral at worst.