In mental health, the treatment plan refers to a written document that outlines the progression of therapy. A treatment plan may be highly formalized or may consist of loosely handwritten notes, depending on the documentation requirements of the insurance company and facility, the preference of the therapist and the severity of the presenting problem. No matter how formalized, however, the treatment plan is always subject to change as therapy progresses.
The treatment plan generally consists of four parts:
Presenting Problem - A brief description of the main issue or issues
Goals of Therapy - An annotated list of both the overall goal(s) and the interim goal(s) of therapy
Methods - A short, annotated list of the techniques that will be used to achieve the goals
Time Estimate - A brief estimate of the length of time and/or number of sessions needed
The client should always be involved in developing the treatment plan, although this is generally accomplished through informal discussion of the situation. Many therapists present a written copy of the treatment plan to the client, although others feel that this can add artificiality to the therapeutic relationship. A copy of the plan, however, should always be available upon request.