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case management, Casework, mental health, Mental health blog, social work

3 tips to co-create an engaging case plan

This is the third post in the Casework 101 series by Social Workin It. Read the previous post here: How to conduct effective case management assessments.

Now that you’ve completed the intake assessment, it’s time to co-create a case plan with the individual you’ll be working with. The keyword being “co-create.” If the person doesn’t have a clear voice in the plan being created for them, they will be less committed to the process and outcomes are likely to suffer. 

Here are three expert tips for creating a case plan that your client is sure to engage with, from an experienced Social Worker and Case Manager.

Be sure to read to the end to find a free downloadable case plan template!

Identify the individual’s goals, barriers, and strengths

Green typewriter with a paper in the feed with the word "Goals" on it.

A case plan begins by outlining the individual’s goals, any barriers to achieving those goals, and the person’s strengths, in their own words. The case plan is, after all, about them. This should be reflected.


Setting goals is one of the single most important parts of case management. Without them, you will not have a clear idea about what the person wants to achieve. Having said that, there are right and wrong ways to set goals.

As much as possible, the goals you set should be SMART goals. In other words, they should be:

SMART goals are specific, measurable, attainable, relevant, and timely.

It’s important to keep in mind that the goals you set depend on the type of service you provide. For example, “improving anxiety symptoms” should not be a goal on your service plan if you are not a Counsellor providing treatment for anxiety. This is the professional equivalent of “staying in your lane.” If you are a Case Manager, however, you could include a goal of “finding free or low-cost treatment options for anxiety.” The intention is to set goals that are based on what your client wants to achieve and that are within your scope, education, and experience.

Similarly, it’s important to set goals that make sense based on the timing of your service. Do you provide a brief, short-term, or long-term service? The wording of goals should reflect this. For example, it doesn’t make sense to set a goal of “earn a three-year diploma in business by 2025” when you provide a brief service. However, as a Brief Service Case Manager, I might include “get connected to local education services in my community to develop a pathway to college plan and apply for available supports” to help the individual take the first step toward achieving that long-term goal.

Ultimately, the goals set should highlight the specific desired outcomes of the work you will do together. Once this is established, you can start developing the path to get there.


Once the goals have been set, the next step is to determine what barriers stand in the way of those goals. Identifying barriers serves two key functions:

  1. To give you a better idea of what has been preventing your client from achieving these goals on their own
  2. To highlight where your interventions should focus

As an example, Person A may be facing challenges remaining housed because they live on a low-income. Person B may find it difficult to keep their housing because of symptoms related to a mental illness. Person B doesn’t have a Doctor or any other supports in place. In the first scenario, the barrier is financial insecurity. In the second scenario, the barrier is a lack of health supports. Both situations have the same result, in that both people may lose their housing if they don’t get help, but the interventions in each case will be very different based on the barriers that are present.

Once you know where the key problems are in the person’s life, you can better direct your referrals, advice, and services to help them overcome those barriers and achieve their goals.


Focusing solely on the barriers in a person’s life is pretty negative and may unexpectedly reinforce everything that is not going right in their life. This can leave the person feeling disengaged and depressed. This is why it’s important to also assess the person’s strengths. Identifying strengths informs three essential purposes:

  1. It reminds the person what they are capable of
  2. It brings the conversation back onto a positive note
  3. It brings the person out of their amygdala and into their prefrontal cortex, which helps the person feel more relaxed, engaged, and motivated

A person’s strengths will also help you determine what steps can be taken by them, what actions they can take on with a little scaffolded support, and what items they need you to take off of their plate entirely. By taking this approach, the person will feel supported but also empowered, which can be beneficial when they face future problems.


Overall, the key to this step is to ask the person directly about their goals, barriers, and strengths and to record these in their own words as much as possible. This will ensure a case plan that is solution-focused, strengths-based, and client-centered.

Create an action plan

Yellow Post-It note on black background with Scrabble tiles spelling out "To do."

Once the goals, barriers, and strengths are clearly laid out, you can put together the action plan. The action plan outlines your plan to help the individual achieve their goals by addressing the presenting barriers using their strengths and your skills.

Begin this process by listing the main presenting issues and any concurrent matters that intersect with them. Issues rarely happen in a vacuum. When someone is in crisis, the presenting problems are almost always creating other issues in their life. Often, the presenting problems are preceded by other issues as well. Include all of the details that are relevant to each challenge.

Next, list any referrals, advice, and/or services given or to be provided that address each of the presenting problems. I like to do this in two columns with the presenting issues in the left column and the corresponding referrals, advice, and services in the right column. I also like to use a checklist-style for all of the items I need to complete so I can check them off as I go and easily refer back. This keeps me organized and is especially helpful when I have a large caseload.

The action plan should also be clear about who will do what. This keeps you and the individual you are supporting accountable for the work to be done.

Finally, make sure to reflect back on the initial goals, barriers, and strengths throughout this process to confirm that each action item serves the desired outcomes.

Develop a contract with the individual and have them sign it

Case Manager holding a pen and paper while the person they are supporting sits with their hands folded on the table. Image is zoomed in on just their hands.

Once you have the case plan completed, there is still one crucial step to complete: developing and signing a contract. A case plan is ultimately useless if the client doesn’t agree to it. The contract solidifies this agreement and ensures everyone is on the same page.

The contract also ensures accountability for you and the individual you are working with. If there is ever a disagreement about what was agreed to, the contract is there to clear things up.

Be specific in the wording of the contract, but not too specific. You want to be clear about the work you are going to do without limiting yourself too much.

Being overly specific puts you in the position of having no wiggle room when new information presents itself. In that case, you will have to book another appointment with the client each time you need to do something that slightly deviates from the original contract. This can be time-consuming for both of you and annoying to the individual you are supporting.

On the other hand, you want to be specific enough that there is a clear ending to your work together. Otherwise, you might unknowingly create false expectations that can damage your professional relationship and negatively impact outcomes.

It is also important to not over-promise. Wording like “I will find a referral for affordable Cognitive Behavioural Therapy” is not wise. Opting for something like “I will research options for Cognitive Behavioural Therapy and make referrals if available” is more appropriate. It is specific enough to show what you will be doing without limiting your work in a significant way, and it’s clear when that item will be completed (even if it ends at the research stage because no resources were available).

Overall, a good contract will itemize each action you agreed to take clearly and concisely and will be dated and signed by both parties. You can find a free downloadable retainer template that I developed at the end of this post.


While the assessment is typically a mess of non-chronological notes, the case plan is your opportunity to organize the assessment into a clear, concise plan that only includes the relevant information to the work you are going to do together. If done correctly, it can serve as a valuable tool in the case management process. As this post clearly lays out, the central component of an effective case plan is that it is co-created with the individual you are helping.

To ensure you have a truly co-created case plan, remember to:

  1. Ask the individual you are working with what their goals, barriers, and strengths are
  2. Discuss options for how you may be able to help them achieve those goals
  3. Ask for their ideas about how you can help them
  4. Come to a mutual decision.

Then all you have to do is put that decision on paper and sign it. That’s it! No fancy trade secrets required. Just good, old fashioned Social Workin It!


As promised, you can download my free case plan template and retainer below! Feel free to use and adapt them for your own needs. These are the actual forms I use in my daily practice as a Brief Service Case Manager, with a few modifications to make them more generalized for your own use.

Downloads available here:

Disclaimer: Tina Cumby is a Social Worker in Ontario Canada. As such, some of the advice in this article may reflect the particular ethical guidelines for social workers in Ontario Canada. When in doubt, refer to the ethical guidelines of your particular mental health profession and the state or province you are licensed to practice in.

Tina Cumby, MSW, RSW
Tina Cumby, MSW, RSW

Tina Cumby, MSW, RSW, is an independent writer and creator of free content for mental health professionals. She has been employed as a social worker for four years and has another year of case management and policy development experience. She works primarily with adults living at the intersections of poverty, disability, and trauma at all levels of practice (micro, mezzo, and macro). Tina is particularly well versed in social work case management and student supervision.

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