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How to Write a Counseling Treatment Plan
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How to Write a Counseling Treatment Plan

Published 
1699948800000
Female therapists sitting on couch discussing how to write a treatment plan
TABLE OF CONTENTS

    If paperwork isn’t your favorite part of being a therapist, you’re not alone. Many clinicians love the personal interactions they get to have in their work, and may put off time-consuming documentation tasks, like completing counseling treatment plans. There are a lot of different types of notes you can use in your private practice, and you may need to use different kinds in different situations. Here is a breakdown of counseling treatment plans, and what you might include in yours.

     

     

    What is a treatment plan in counseling?

     

    A treatment plan is a document in each client file that identifies the goals, plan, and method of therapy that the clinician and client agree to move forward with. It’s the clinician’s guide to identify how a client is progressing, and is a platform for dialogue about treatment satisfaction. When a clinician co-constructs a treatment plan with the client, the client can easily buy into the process—which creates rapport, and an agreed upon path towards symptom reduction.


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    What should a counseling treatment plan include?

     

    A counseling treatment plan typically will include one or more goals, objectives, and interventions. It will also usually include space for your client’s personal information, psychological history, and demographics, as well as a space for tracking progress. One goal may have multiple objectives and interventions if the clinician will be recommending more than one approach. This is important in culturally responsive therapy where collateral support may be needed such as inclusion of spiritual leaders, community partners, or family members. 

     

    Here are the components of a treatment plan broken down with more specifics:

     

    Goal:

    The goal of your treatment plan should be a broad statement about what the client would like to accomplish in therapy. While it’s ultimately your job as the clinician to put the treatment plan together as part of clinical documentation, the plan can be designed in session in collaboration with the client to make sure they’re fully involved and invested in the process. 

     

    You can ask your client what they hope to have achieved or accomplished by the time they’re done in therapy, or what they’d like to see be different in their life when they’re done. If this is too future-oriented for your client, or if they’re struggling to name any goals, you can share a few general ideas, and ask questions to help tailor the goals to fit their therapeutic needs.

     

    Objective:

    Your treatment plan objective should be a realistic, measurable, time-framed, and achievable description of your goal. If your objective is too broad—or doesn’t include measurable time frames—it’ll be hard for you or your clients to know if you’ve actually made any progress together. By narrowing your focus and keeping this section very clear, it’ll be easier for you both to track how your clients are doing. 


    Intervention:

    The intervention section of your treatment plan should lay out what method will be used to achieve the goal. You can also include details like who will provide the intervention, what will the intervention be, when (the duration and frequency) and where will the intervention take place.

     

    When it comes to the intervention, keep in mind that the client may have a good idea of what has already worked for them and what hasn’t. If a client has been in counseling before, you can ask them what they’ve liked or disliked in therapy before, and use that (where clinically appropriate) to inform your plans. 

     

    This is also a good time to discuss if your client has any additional people, spiritual practices, culturally relevant practices, or rituals they would like to see incorporated into the intervention. Depending on how they respond, you may want to get a release of information to have someone intermittently join sessions, or to share information outside of a session. This approach would work best for clients who are used to a more collectivist style of healing, or who have a worldview that conflicts with the usual 1-to-1 therapy model. 

     

     

    Counseling treatment plan example 

     

    Here is an example of what a counseling treatment might look like to help give each section more context. 

     

    Goal: The client will experience days that are free from anxiety

     

    Objective: In 8 weeks, the client will learn and implement three skills to reduce experiencing anxiety symptoms from seven days a week to three or fewer days a week.

     

    Intervention: I/we will use breathwork protocols, M-CBT and talk therapy to help the client develop a minimum of 3 skills to reduce anxiety symptoms. It is recommended that the client attend weekly 50-minute telehealth sessions for 8 weeks. 

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    Why are treatment plans important in counseling?

     

    Therapy is one of the few places where a client gets to take part in the design of their treatment, and that can be very empowering. It could also be overwhelming, and some may simply be unable to participate in the goal-planning process. But at the very least, the client should be presented with the treatment plan and asked if they agree with it, and if there’s anything they would like to discuss changing. 

     

    A treatment plan is a working document that will be updated depending on the progression of treatment. On occasion, you might want to change a treatment goal altogether, or pause one goal to focus on a more acute issue. It’s not likely that you’ll focus on every goal in every session. The work you do will depend on the needs of the client on a given day, and clients may have more than one goal they are trying to achieve. 

     

    It’s also important to review your treatment plans regularly, so that you know when a client isn’t making progress toward a specific goal. If you notice this happening often, it might be a good time to seek consultation for an outside perspective on whether you’ve identified the true clinical need or not. If your plan appears to address the right therapeutic need and your client still isn’t making progress, it might be time to refer out. Not every therapist is a good fit for every client, and sometimes a different approach or clinician will prompt the change the client is hoping a treatment plan will facilitate. 

     

     

    How to use treatment plans with your EHR

     

    To create treatment plans with your EHR, you can either upload a template of your own, or follow the structure within your software. Most top-rated EHRs will have a dedicated section for notes and documentation, as well as a template library with easy-to-use templates that are built right into the platform. 

     

    If you’re looking for a fully integrated EHR that works for behavioral health practitioners like you, try SimplePractice for a free 30 days. SimplePractice makes it easy to streamline your notes and documentation, while also improving your clients’ experience. 

     

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