Individual Treatment Plans

Treatment plans are documentation tools that allow practitioners and those treating them to design and monitor treatment. Plans are often considered essential to providing well-rounded health care. We use treatment plans as blueprints to outline the services provided. The treatment plans typically highlight important assessment information, define areas of concern and establish concrete goals for treatment.

Effective mental health treatment plans often contain the following:

• History, assessment, and demographics: This section includes basic
  demographic information, psychosocial history, the onset of symptoms,
  diagnoses (past and present), treatment history, and other assessment
  information pertinent to well-being.
• Presenting concerns:This section details the current concerns and mental health issues that led the individual to seek treatment.
• Treatment contract:The treatment contract summarizes the goals for change, often a mutually agreed-upon plan for what will be worked on. It usually details who is responsible for what and what treatment modality will be used.
• Strengths:Throughout the plan, we often include information about the
  perceived strengths of the person in treatment. This can empower individuals to tap into their areas of strength to achieve their goals.
• Modality, frequency, and targets:Throughout the plan, each goal typically includes the type of treatment modality used to achieve it. The frequency of sessions and target dates for completion are also often included.
• Treatment goals:These are the building blocks of the treatment plan. They are designed to be specific, realistic, and tailored to the needs of the person in therapy. The language will also meet the person on their level. Goals are usually measurable – rating scales, target percentages, and behavioral tracking can be incorporated into the goal language to ensure that it is measurable.
• Objectives:Goals are often broken down into objectives to support the person in therapy by taking small, achievable steps toward completing the larger goal.
• Interventions:Goals usually include the various techniques and interventions we will implement to support the achievement of the larger goal.
• Progress and outcomes: Documenting progress toward goals is considered to be one of the most important aspects of a treatment plan. Progress and outcomes of the work are documented under each goal. When the treatment plan is reviewed, the progress sections summarize how things are going within and outside sessions. This portion of the treatment plan will often intersect with clinical progress notes.

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