Biographical Information
Basic information about the client which may include demographics, sexuality, age, mental health history, family history and dynamics.

Presenting Problem
The reason they have come for therapy.

Assessments
What other assessments (medical or psychological) do you need to undertake to determine appropriate tailored treatment plans.

Developmental and Maintaining Processes
- Predisposing: factors that have existed in client’s life that have made them more vulnerable and susceptible to current symptoms and problems. These may include biological, social, distal, proximal.
- Precipitating: immediate factors that has triggered the problems that lead to the client attending therapy. ie. what bought them here.
- Perpetuating: factors that maintain the problem and keep it going.
- Protective: factors that increase the client’s personal and social resources, positive attributes.
Person’s 6 Step

Goals
Together with client come up with goals that the client would like to achieve with the help of the therapist and therapy.

Treatment
Treatment plans should be tailored and individual. One thing that can help someone may not necessarily help someone else with similar symptoms. Treatments can be planned from differing perspective from different schools of thoughts such as cognitive behavioural therapy (CBT), person centred therapy, psychoanalytical, humanistic, gestalt etc.