Therapy Treatment Plan Template

The template

Treatment Plan
Client: [identifier]   Date: [date]   Clinician: [name, credentials]
Review date: [date]

1. Presenting concerns (client's words): [ ]
2. Diagnosis or clinical impression: [if within your license's scope]
3. Strengths and supports: [ ]
4. Client's own goals for therapy: [in their words]

Problem 1: [specific problem, stated in behavioral terms]
  Long-term goal: [the change the client wants]
  Objective 1a: [measurable step, with a number and a target date]
  Objective 1b: [ ]
  Interventions: [what you will do, how often]
  How progress will be measured: [measure, rating or count]

Problem 2: [ ]
  Long-term goal: [ ]
  Objective 2a: [ ]
  Interventions: [ ]
  How progress will be measured: [ ]

Safety plan: [in place / not indicated; date reviewed]
Frequency and modality: [for example, weekly individual CBT, 50 minutes]
Referrals and coordination: [ ]
Client participation: [how the client was involved in writing the plan]
Signatures and dates: [client, clinician]

Goals, objectives and interventions

Problem. One specific difficulty, described in terms of what the client does or experiences: "avoids leaving home alone; has missed work twice this month" is clearer than "agoraphobia".

Long-term goal. The broad change the client wants, ideally in their own words: "feel able to go places on my own".

Objectives. The measurable steps toward the goal. A useful check is SMART: specific, measurable, achievable, relevant and time-bound. "Client will take a 10-minute walk alone three times a week by March 1" can be checked. "Client will feel less anxious" cannot, unless you attach a measure and a target.

Interventions. What you will do, named specifically, and how often: "graded exposure to leaving home, weekly sessions" rather than "provided support".

Measurement. The scale, rating or count you will use to track each objective, such as a standardized measure, a 0 to 10 rating or a weekly count.

Safety. If you identify suicide risk, write a safety plan with the client and set when you will review it. Include crisis resources such as the 988 Suicide and Crisis Lifeline and steps to reduce access to lethal means.

A filled example

All examples on this page are fictional composites. They do not describe real clients.

Treatment Plan
Client: adult in their 40s   Review date: 90 days from today

1. Presenting concerns: "Since the separation I can't sleep, I snap at the
   kids, and I've stopped seeing friends."
2. Clinical impression: adjustment difficulties following a separation, with
   low mood and irritability. [Diagnosis if within scope.]
3. Strengths: close sibling, steady job, motivated, previous good response to
   counseling.
4. Client's goals: "Sleep properly and feel like myself again."

Problem 1: Sleeping 4 to 5 hours a night; lies awake worrying.
  Long-term goal: Sleep enough to function well at work and at home.
  Objective 1a: Sleep at least 6.5 hours on 5 of 7 nights, by sleep diary,
  within 8 weeks.
  Objective 1b: Use a wind-down routine on 5 of 7 nights within 4 weeks.
  Interventions: Sleep hygiene and stimulus control; scheduled worry time;
  weekly review of the sleep diary.
  Measurement: Sleep diary; weekly 0 to 10 sleep-quality rating.

Problem 2: Withdrawn from friends since the separation.
  Long-term goal: Rebuild social support.
  Objective 2a: Contact one friend a week for 6 weeks.
  Objective 2b: Attend one social activity every two weeks by week 8.
  Interventions: Behavioral activation; problem-solving about barriers.
  Measurement: Weekly activity log.

Mood measure: PHQ-9 at intake and at each review.
Safety plan: Not indicated; on intake risk screen, client denies suicidal
ideation, intent or past attempts. Reassess at each session.
Frequency and modality: Weekly individual CBT, 50 minutes.
Referrals and coordination: Client to discuss sleep with their primary care
provider to check for medical causes and medication effects; refer for CBT-I
if sleep has not improved by week 8. Coordinate with written consent if
needed.
Client participation: Goals and objectives written with the client in session 2.

Common mistakes

1. Objectives that cannot be measured. "Improve mood" needs a measure and a target.
2. Clinician goals, not client goals. Write the goals with the client, in their words where possible.
3. Generic interventions. Name what you will actually do.
4. A plan written once and never reviewed. Set a review date and update the plan when goals are met or change.
5. Progress notes that never mention the plan. Each note should say which goal the session addressed.

For goals, objectives and a sample plan for depression, see the depression treatment plan.

FAQ

What should a therapy treatment plan include?
The presenting concerns, strengths, the client's goals, specific problems with long-term goals, measurable objectives, the interventions you will use, how progress will be measured, a review date and signatures. Your setting or payer may require more, such as a diagnosis.

What is the difference between a goal and an objective?
A goal is the broad change the client wants. An objective is a measurable step toward it, with a number and a date.

How often should a treatment plan be reviewed?
Your agency, payer or licensing board may set a schedule. Without one, review at a date you set, when goals are met and when the client's situation changes.

Can you write a treatment plan without a diagnosis?
Yes, if you do not bill insurance and your setting does not require one. Insurance usually requires a diagnosis, and only clinicians whose license allows it can make one.

This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.