SOCIAL WORK TREATMENT PLAN

Client: [Name or ID]
Date of birth: [Date]
Plan date: [Date]
Plan type: [Initial plan, or review number and the date of the last plan]
Service: [Hospital, community agency, school, child and family services, or other setting]
Social worker: [Name, credentials, direct phone]
Based on: [Assessment type and date, screens used, records, and collateral sources]
Planned with: [Client, and any family, guardian, interpreter, or support person present]

PERSON-IN-ENVIRONMENT NEEDS
Housing: [Where the client lives, how stable and safe it is, access, or no need]
Income and benefits: [Sources of income, gaps, benefits in place or not yet applied for]
Food and basic needs: [Food security, utilities, phone, clothing, transport]
Health and functioning: [Conditions, daily activities, equipment, medicines, access to care]
Mental health and substance use: [Concerns raised, screen results, current care]
Family and caregiving: [Household, who cares for whom, child care, conflict]
Safety: [Abuse, neglect, exploitation, partner violence, self-harm, falls, or none identified]
Legal: [Eviction, custody, guardianship, immigration, criminal matters, or none]
School or work: [Enrollment and attendance, job, leave, barriers]
Social connection: [Friends, community groups, faith, isolation]

PRIORITIES AND STRENGTHS
Client's priorities: [The needs the client wants to work on, in the order they chose]
In the client's words: [What the client wants to be different]
Strengths and resources: [Skills, people, past successes, services already in place]
Barriers: [Cost, transport, language, eligibility rules, wait lists, mistrust of services]

GOALS, OBJECTIVES, AND ACTIONS
Goal 1: [The change the client wants, in their words where possible]
Objective 1a: [A step that can be checked, how it will be checked, and the target date]
Actions for 1a: [Each step, its owner: client, social worker, family, or another agency, and the due date]
Objective 1b: [A step that can be checked, how it will be checked, and the target date]
Actions for 1b: [Each step, its owner, and the due date]
Goal 2: [The change the client wants]
Objective 2a: [A step that can be checked, how it will be checked, and the target date]
Actions for 2a: [Each step, its owner, and the due date]

REFERRALS AND CARE COORDINATION
Referral 1: [Agency or service, reason, date sent, status: sent, accepted, waitlisted, or declined]
Referral 2: [Agency or service, reason, date sent, status]
Contacts: [Each person or agency in the plan, their part in it, phone or email]
Coordination lead: [Who keeps the plan moving, and the client's main contact]
Consent to share: [Who may receive information, what may be shared, date signed, end date]

SAFETY AND CONTINGENCY
Safety plan: [In place with the date reviewed, or not indicated and why]
If a step fails: [Backup for each deadline: a refused referral, a missed date, a crisis]
Crisis contacts: [988 call or text, 911, local crisis or after-hours line]

REVIEW AND AGREEMENT
Review date: [Date, and the events that bring it forward]
Closing or transition: [What will show the client no longer needs this service, or is moving to another]
Client's view: [Agreement, changes the client asked for, and anything they declined]
Copies to: [Client, and others named in the consent]
Client signature: [Signature and date]
Social worker signature: [Name, credentials, signature, date]