ࡱ> `b_ @  Bbjbj{{ *J("""""""6>#>#>#8v#$#6/R$Z%%%%&'!(L2/4/4/4/4/4/4/$0R+3X/E"(&&((X/""%%/J+J+J+(."%"%2/J+(2/J+J+""J+%F$ Eݓ>#")"J++|/0/J+3D)3J+66""""3"J+lm((J+( (Ym(m(m(X/X/66Dz 4+66zDSS COUNSELING SERVICES ASSESSMENT AND TREATMENT PLAN REPORTDepartment of Human ServicesContract Provider NameContract Number or Provider Number FORMTEXT       FORMTEXT      AddressPhone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      Client NameCase NumberDate of Birth FORMTEXT       FORMTEXT       FORMTEXT      Date of ReportService Period FORMTEXT      From FORMTEXT      To FORMTEXT      1.List appointment dates scheduled for client: FORMTEXT      2.List dates client attended sessions: FORMTEXT      3.List all phone calls or other contacts made: FORMTEXT      4.Working Diagnosis and Employability Assesment: FORMTEXT      5.Individual or Family Assessment: FORMTEXT      6.Identified Concerns and Client Strengths: FORMTEXT      7.Recommendation on Employability: FORMTEXT      8.Specific Objectives and Time Frames: FORMTEXT      Sz|2 4 H J L V X Z \ p r t ~     $ & * @ B X Z t v x z jh VUj^h VUjh VUjvh VUjh VUjhIUmHnHujh VUh| jh| U hu;hu; hu;5hu;h7~8z|sj $Ifgd(,<kdX$$Ifl4y,y,4 lalf4 $Ifgdu;<kd$$Ifl4y,y,4 lalf4 $Ifgdu;AB0 2 Z i`` $Ifgdu;Okd$$Ifl40T!y,T!% 4 lalf4 $Ifgdu;<kd$$Ifl4y,y,4 lalf4 ( VMM $Ifgd| Okd$$Ifl40Z!y,Z! 4 lalf4 $Ifgdu;Okdr$$Ifl40T!y,T!% 4 lalf4( * B Z v x C: $Ifgd| bkdT$$Ifl4F<Z!y,<      4 lalf4 $Ifgd| Okd$$Ifl40Z!y,Z! 4 lalf4 0 2 4 H J L V X d f z | ~ $ & : < > H J 梞梞jhG&2Uj hG&2UhG&2jhG&2Uj h VUj$ h VUjh VU h| 5jh VUj`h VUh| jh| UjhIUmHnHu5  . 0 $Ifgd| bkdH$$Ifl4F<Z!y,<      4 lalf4 $Ifgd| 0 2 Z d $$Ifa$gd| ($Ifgd| bkd$$Ifl4F<hy,<,      4 lalf4 vm0$ $$Ifa$gd| <kd $$Ifl4py,y,4 lalf4 $Ifgd(,kd $$Ifl4r<hH!y,<1 4 lalf4 " $ L N P <Okdx $$Ifl4X0y,*4 lalf4 ($IfgdG&2 $$Ifa$gdG&2Okdd $$Ifl40y,*4 lalf4 $$Ifa$gd| P R X fZO ($IfgdG&2 $$Ifa$gdG&2Okd| $$Ifl40y,*4 lalf4 $$Ifa$gd| <kd $$Ifl4y,y,4 lalf4 8 : N P R \ ^ HJ^`blnNPdfhrt|~>ҩҞҚዉUh VjhG&2UhLjh7~Ujh7~UjzhG&2UjbhG&2UjJhG&2Uh7~j2hG&2UhG&2h| jhIUmHnHujhG&2U6 4 f<kd($$Ifl4y,y,4 lalf4 $$Ifa$gd| Okd$$Ifl4X0y,*4 lalf44 6 8 ` b d H< $$Ifa$gd| Okd$$Ifl4X0y,*4 lalf4 ($IfgdG&2 $$Ifa$gdG&2Okd$$Ifl40y,*4 lalf4d f l fZO ($IfgdG&2 $$Ifa$gdG&2Okd$$Ifl40y,*4 lalf4 $$Ifa$gd| <kd@$$Ifl4y,y,4 lalf4 Df<kdX$$Ifl4y,y,4 lalf4 $$Ifa$gd| Okd$$Ifl4X0y,*4 lalf4DFHprtH< $$Ifa$gd| Okd$$Ifl4X0y,*4 lalf4 ($IfgdG&2 $$Ifa$gdG&2Okd$$Ifl40y,*4 lalf4tv|fZO ($IfgdG&2 $$Ifa$gdG&2Okd$$Ifl40y,*4 lalf4 $$Ifa$gd| <kdp$$Ifl4y,y,4 lalf4JfZZ $$Ifa$gdL<kd$$Ifl4y,y,4 lalf4 $$Ifa$gd| Okd$$Ifl4X0y,*4 lalf4JLNvxzHOkd$$Ifl4X0y,*4 lalf4 ($IfgdL $$Ifa$gdLOkd$$Ifl40y,*4 lalf4z|fZO ($IfgdG&2 $$Ifa$gdG&2Okd $$Ifl40y,*4 lalf4 $$Ifa$gd| <kd$$Ifl4y,y,4 lalf4<>F>i`` $Ifgd V<kd$$Ifl4py,y,4 lalf4 $$Ifa$gd| Lkd $$IflX0y,*4 lalignature of Contract ProviderDateDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. 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