Psychology Treatment Plan Document Template
Description:
This template is designed for therapists to create a comprehensive psychology treatment plan after the initial assessment, outlining goals, strategies, and interventions to facilitate the client's healing process. It is intended to be general and adaptable to various therapeutic approaches and mental health conditions.
Note:
Use this template to document the treatment plan post-assessment. Adjust sections based on the client’s specific needs and the therapeutic approach being used.
Date: [Record the date the treatment plan is created]
Client Name: [Enter the client’s full legal name]
Date of Birth: [Record the client’s date of birth in MM/DD/YYYY format]
Age: [Note the client’s current age]
Therapist Name: [Enter the therapist’s full name]
Client Information:
Diagnosis: [Note the client’s current mental health diagnosis, if applicable, based on assessment.]
Relevant History: [Detail any relevant past mental health history, medical conditions, substance use, or previous therapy, to provide context for the treatment plan.]
Current Symptoms and Functioning: [Describe the client’s current symptoms, behaviors, and functional impairments, based on recent assessments.]
Treatment Goals:
Long-term Goals: [List the overarching goals for therapy, such as improving quality of life or reducing symptom severity.]
Short-term Objectives: [Detail specific, measurable, achievable, relevant, and time-bound (SMART) objectives to work towards long-term goals, such as reducing anxiety by 50% in 8 weeks.]
Client Input: [Note the client’s input on their goals and any preferences for treatment.]
Interventions and Strategies:
Therapeutic Approach: [Outline the specific therapeutic modalities to be used, such as cognitive-behavioral therapy (CBT), psychodynamic therapy, or mindfulness-based therapy.]
Frequency and Duration: [Specify how often sessions will occur (e.g., weekly) and the anticipated duration of treatment (e.g., 12 weeks).]
Specific Interventions: [Detail the specific techniques or strategies to be implemented, such as cognitive restructuring, exposure therapy, or relaxation training.]
Progress Monitoring:
Standardized Measures: [Note any standardized tools or tests to be used for tracking progress, such as PHQ-9 for depression or GAD-7 for anxiety, including frequency of administration.]
Progress Review Schedule: [Specify how often the treatment plan will be reviewed (e.g., every 3 months) to assess effectiveness and make adjustments.]
Medication Monitoring: [If applicable, note how medication will be monitored, including any coordination with prescribing physicians.]
Risk Assessment:
Identified Risks: [Assess any risks related to the client’s mental health, such as suicidal ideation, self-harm, or significant functional impairment.]
Protective Factors: [Identify strengths or resources that can mitigate risks, such as family support, coping skills, or treatment engagement.]
Safety Plan: [Outline any safety measures or plans in place, such as crisis contacts or emergency protocols.]
Therapist’s Signature and Date:
[Signature and date of the therapist]
Psychology Treatment Plan Document Template (Filled Mock Plan)
Date: March 1, 2025
Client Name: Emily Johnson
Date of Birth: 05/15/1995
Age: 29
Therapist Name: Dr. Sarah Thompson
Client Information:
Diagnosis: Generalized Anxiety Disorder (GAD), mild depression.
Relevant History: No previous mental health diagnoses, occasional tension headaches, no substance use. Past therapy for stress in college, found it helpful.
Current Symptoms and Functioning: Reports frequent worry, difficulty concentrating, especially at work, and low mood with occasional crying spells. Impacts work performance and family engagement.
Treatment Goals:
Long-term Goals: Reduce anxiety and depression symptoms to improve quality of life and work functioning.
Short-term Objectives: Reduce anxiety by 50% within 8 weeks, as measured by GAD-7, and increase engagement in family activities by scheduling one weekly activity within 4 weeks.
Client Input: Emily wants to feel less anxious at work and be more present with her family, and prefers in-person sessions.
Interventions and Strategies:
Therapeutic Approach: Cognitive Behavioral Therapy (CBT), including cognitive restructuring and behavioral activation.
Frequency and Duration: Weekly 50-minute sessions for 12 weeks, with monthly follow-up sessions thereafter.
Specific Interventions: Cognitive restructuring to challenge negative thoughts, relaxation techniques for anxiety management, and scheduling enjoyable activities to combat low mood.
Progress Monitoring:
Standardized Measures: Use GAD-7 and PHQ-9 every 4 weeks to track anxiety and depression.
Progress Review Schedule: Review treatment plan every 3 months to assess effectiveness and make adjustments.
Medication Monitoring: Coordinate with the prescribing physician for antidepressant medication, and monitor side effects and adherence monthly.
Risk Assessment:
Identified Risks: Denies suicidal ideation, but reports occasional passive thoughts of “not wanting to go on” during high stress.
Protective Factors: Strong family support, good social network, and motivation for therapy.
Safety Plan: Contact a therapist or 988 crisis line if thoughts intensify, family to check in weekly.
Therapist’s Signature and Date:
Dr. Sarah Thompson, March 1, 2025