<p> Case Summary for Supervision & Consultation</p><p>Family: Therapist: Date: </p><p>Genogram REASONS FOR REFERRAL</p><p>Behavior Frequency Intensity Duration System Affected (phys (how often does (how bad is it? (how long has (Individual, aggression, it occur?) describe) the problem family, school, runaway, existed?) peer, truancy, etc) community) Non-compliant with his probation terms</p><p>Failing Grades</p><p>Skipping School</p><p>Smoking Marijuana</p><p>Gang affiliation </p><p>Physical aggression at school </p><p>Initial Goals\Desired Outcome</p><p>*Key Desired Outcome(s) Participant Relationship to Youth (what do you want to see by the end of 2 (name) treatment – in the next 3-5 months?) Client </p><p>MST Therapist</p><p>Court Counselor</p><p>*ALL invested persons, including extended family supports, youth siblings, school staff, court staff / probation, MST therapist, Children’s Services worker, etc</p><p>FAMILY Strengths Systemic Weaknesses\Needs</p><p>(include caregiver   relationships, team  parenting, parenting styles, level of conflict, extended family support,</p><p> etc.) SCHOOL (include availability of   extracurricular activities, academic assistance and programming, home- school communication, disciplinary practices, etc.) PEERS   (include mix of positive vs. negative peers, peer activities & involvements, impact of peers on youth behaviors)</p><p>COMMUNITY   </p><p>(include local resources, youth programs,, police presence, criminal / drug / gang activity, etc.)</p><p>INDIVIDUAL  </p><p>(include youth skills, talents, abilities, interests, & attributes, as well as behavioral issue</p><p>6. Barriers to Previous Intermediary Goals: (Factors that interfered with the achievement (Met) of all your previous IG’s above or new information you have acquired about things that will impede treatment progress overall.)Principle #8</p><p>7. Advances in Treatment: Gains that were made toward achieving last week’s IG’s or new information you have acquired about things that will contribute to treatment progress.) Please explain how you met your goals and provide the referenced documents (behavioral plan, </p><p>4 safety plan, retrieval plan, etc) and how you will measure the effectiveness of your interventions Principle#8.</p><p>8. Assessment of the “fit” between problems and their systemic context ( Individual, Family, School, Peer, and Community drivers (as evidenced by…)the justification of each driver within each context. (Include only current fits or fits that apply to current presenting issue) </p><p>Goals Met Partial Not IG 1</p><p>6 IG 2</p><p>10. Questions for supervision/consultation: </p><p>11. Supervision Feedback:</p><p>12. Consultation Feedback:</p><p>Supervisor Signature Date MST Therapist Signature Date</p>