Canon City Counseling, Inc. www.canoncitycounseling.com 224 N. Cottonwood Avenue

Telephone: 719-276-0292

Canon City, CO 81212

FAX: 719-276-0292

Domestic Violence Treatment Plan Client Name:

Date: 8/15/2013

Next Review Date: 11/8/2013

Treatment: Domestic Violence Therapy

Monitored Sobriety:

UA Walk-in

Groups Attended: Groups Excused: Groups No Show:

16 of 0

Sessions Attended: Sessions Excused: Sessions No Show:

10 0 0

Court Case #:

12M376

Monitored Sobriety: Sessions Attended: Sessions Excused: Sessions No Show:

Initial Level at Intake: C Recommended Level as of this Date: C Second Weekly Clinical Contact: Level II Therapy:

1. Goal: 1.0 Mr. XYZ will not use alcohol or illegal substances as demonstrated through negative monitored sobriety. Objectives: 1.1 Mr. XYZ will participate in weekly Level II Therapy providing feedback weekly. 1.2 Mr. XYZ will participate in monitored sobriety with no absences.

2. Goal:

2.0 Mr. XYZ will successfully complete competencies of DV treatment as evidenced through his approved Personal Change Plan. Objectives: 2.1 Mr. XYZ will complete homework as assigned. 2.2 Mr. XYZ will provide feedback to peers weekly using “I” statements and using personal experiences as examples.

3. Goal:

3.0 Mr. XYZ will understand how family interactions impact behavioral choices and will identify on weekly check in sheet examples of beliefs originated in family of origin. Objectives: 3.1 Mr. XYZ will set one boundary with family weekly and discuss in group. 3.2 Mr. XYZ will reinforce boundaries set by stating facts and using boundary action statements.

Comments: .

__________________________________________________ Client Signature

________________________________ Date

*Your signature on this document indicates that you have received a copy, and that you are responsible for the successful completion and demonstration of all components.