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Free LMFT Case Presentation & Treatment Plan Template (Fillable) | Triangle Therapist

Client Details and Group Supervision Report

Complete before your supervisory session. Use a pseudonym for the counselee — never the client’s real name. Nothing typed here is saved by the page; use Print / Save as PDF when finished.

Cultural Considerations — age, ethnicity, race, gender, sexual orientation, etc.

Nature of the Relationship, Number and Duration of the Counseling Sessions

Marital / Co-habitation History

Family of Origin Summary

Initial Presenting Problem(s)

History of the Problem(s) (include prior treatment, hospitalization, etc.)

Genogram Completed?

Trauma History / Critical Incidents

Systemic Diagnoses (including circumplex diagnosis, marital satisfaction, psycho-physiological reactions, multigenerational processes, significant triangles, cut-offs, etc.)

Integrative Pastoral Impressions (if provided: spiritual beliefs, religious involvement)

Personality, Other Pertinent Information (Enneatype, Myers-Briggs, education level, occupation)

Psychosocial and Environmental Issues (list and describe)

Problems with primary support group; social environment; educational; occupational; housing; economic; access to health care; interaction with the legal system; other psychosocial and environmental problems.

Treatment Plan

What therapeutic interventions are you considering? What psycho-educational resources might you recommend? What pastoral and theological issues are you going to address, and how?

Diagnosis — Clinical Disorder, Condition or Problem(s)

Other Conditions That May Be a Focus of Clinical Attention or Rule Out

Problems in Order of Client Concern

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Client Goals

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Model / Models

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Interventions

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Improvement / Goal Measurement Method(s)

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Self-Evaluation and Questions for Supervision

What concerns do you want to focus on in this supervisory session? What issues does this case study raise for you in terms of your own transference to the case? Do you feel any discernible projective identifications? How would you critique your counseling interventions?

Confidentiality reminder: this page does not save or transmit anything you type, but the PDF you create will contain clinical information. Use pseudonyms, store the file securely, and share it only through channels approved by your program and agency.