Psychology Treatment Plan Review Note Template
Description:
This template is designed for documenting dedicated sessions where the therapist and client review the treatment plan, assessing progress, and making any necessary adjustments. It is intended to ensure the treatment plan remains effective and aligned with the client’s needs.
Note:
Use this template for sessions specifically dedicated to reviewing the treatment plan. Adjust sections based on the client’s specific needs and the therapeutic approach being used.
Date: [Record the date of the review session]
Session Number: [Note the session number in the sequence of therapy]
Client Name: [Enter the client’s full legal name]
Therapist Name: [Enter the therapist’s full name]
Check-in:
Current State and Symptoms: [Note the client's current mental state, any recent changes in symptoms relevant to their condition.]
Recent Events: [Detail any significant events or stressors that may be impacting their mental health.]
Review of Treatment Plan:
Original Goals and Objectives: [List the goals and objectives from the initial treatment plan.]
Progress towards Each Goal: [Assess the progress for each goal: achieved, partially achieved, not achieved.]
Interventions Used and Their Effectiveness: [Detail the interventions implemented and their impact on the client's condition.]
Assessments:
Standardized Measures: [Note any standardized tests or measures used and their current scores, comparing them to initial scores.]
Other Observations: [Record any other relevant assessments or observations.]
Client Feedback:
Satisfaction with Treatment: [Note the client's satisfaction level with the treatment plan and therapy process.]
Suggestions for Changes: [Record any suggestions or preferences the client has for modifying the treatment plan.]
Adjustments to Treatment Plan:
Decision on Treatment Plan: [State whether the treatment plan is to be continued, modified, or terminated.]
Changes to Goals or Objectives: [Outline any modifications to the original goals or objectives.]
New or Modified Interventions: [Detail any new interventions or changes to existing ones.]
Rationale for Changes: [Explain the reasons behind the adjustments.]
Recommendations and Referrals: [Note any specific recommendations or referrals made during the review.]
Future Plan:
Next Steps: [Outline the next steps in the therapy process, including any scheduled sessions or activities.]
Follow-up Reviews: [Specify the schedule for future treatment plan reviews.]
Risk Assessment:
Current Risk Level: [Assess any current risks related to the client's mental health.]
Protective Factors: [Identify strengths or resources that can mitigate risks.]
Therapist's Observations and Impressions:
[Record the therapist's overall impressions of the review, any concerns, and recommendations for future sessions.]
Psychology Treatment Plan Review Note Template (Filled Mock Session)
Date: June 15, 2025
Session Number: 6
Client Name: John Doe
Therapist Name: Dr. Emily Brown
Check-in:
Current State and Symptoms: John reports feeling more stable, with fewer depressive episodes. He still experiences some anxiety but feels it's manageable.
Recent Events: He started a new job last month, which has been challenging but also exciting.
Review of Treatment Plan:
Original Goals and Objectives:
Reduce depression symptoms (PHQ-9 score from 15 to below 10).
Improve work performance and job satisfaction.
Progress towards Each Goal:
PHQ-9 score is now 8, which is below 10. Goal achieved.
He has been performing well at his new job and reports higher job satisfaction. Goal partially achieved; he still feels some stress but is managing it better.
Interventions Used and Their Effectiveness:
Cognitive Behavioral Therapy (CBT) for depression and anxiety, effective in reducing symptoms.
Mindfulness meditation for stress management, helpful in improving coping skills.
Assessments:
Standardized Measures:
PHQ-9: Initial score 15, current score 8.
GAD-7: Initial score 12, current score 6.
Other Observations:
John has been more engaged in social activities and reports better relationships with friends and family.
Client Feedback:
Satisfaction with Treatment: John is very satisfied with the progress and feels that therapy has been helpful.
Suggestions for Changes: He would like to focus more on work-life balance and time management in future sessions.
Adjustments to Treatment Plan:
Decision on Treatment Plan: Continue with modifications.
Changes to Goals or Objectives: Add new goal: Improve work-life balance and time management.
New or Modified Interventions: Continue CBT with a focus on time management and setting boundaries; introduce relaxation techniques for work-related stress.
Rationale for Changes: To address John's request and further enhance his overall well-being and functioning.
Recommendations and Referrals: Recommend a stress management workshop if needed.
Future Plan:
Next Steps: Continue weekly sessions for the next 4 weeks, then switch to bi-weekly.
Follow-up Reviews: Schedule the next treatment plan review in 3 months.
Risk Assessment:
Current Risk Level: Low. No thoughts of self-harm or suicide.
Protective Factors: Strong family support, new job, and improved mental health.
Therapist's Observations and Impressions:
John has made significant progress and is actively engaging with his treatment. The new goal aligns with his current needs, and the adjusted interventions should help him achieve better work-life balance.