Treatment Plan Summary

MENTAL HEALTH CARE TREATMENT PLAN

This treatment plan summary contains information that will appear in the client account portal medical chart in the electronic health records software (TherapyNotes LLC). The sections of this plan chosen by the client auto-fill into every progress note drafted and is acknowledged and signed by the clinician. If you are a current client working with me in therapy sessions, please read this document carefully, the areas of this plan that you contribute to will be referenced.

Clinician: ________________________ The clinician’s contact info, license number, and national provider identification number will be noted on every plan.

Patient: __________________________ Date of Birth: ____________________________

Payer: ___________________________ Date and Time: ___________________________

Client’s Account Number: _________________

Diagnosis

ICD-10	Description



Diagnostic justification and/or assessment measures are documented here

Presenting Problem:

Information generated from the client history form will be listed here in the electronic health records plan.
Information from any assessments, outcome measures, and diagnostic interviews will be listed here in the plan.
The clinician’s observations of the client’s orientation, appearance, attire, behaviors, and mental status exam will be listed here in the plan.

The client’s reported symptoms
* listed here, in their own words

The Long-Term Goals for Therapy:

In 12 months, or at the conclusion of therapy and treatment with the clinician, the client will have achieved the following goals below, as evidenced by the regular treatment plan revisions and updates tracked on the plan and in progress notes. The goals listed here are relevant to any client engaging in this therapy program. If these goals have not been met, and the client still believes therapy is helpful, and would like to continue working on achieving these goals, their treatment plan will have to be revised and signed again.

There will be an objectively and subjectively noticeable decrease in the frequency and duration of client’s reported and observed symptoms, behaviors, and problems, related to their diagnoses, so that their daily functioning is no longer impaired.
There will be an objectively and subjectively noticeable reduction in the severity and impact of the client’s reported and observed symptoms, behaviors, and problems, related to their diagnoses, so that their daily functioning is no longer impaired.
The client will have lowered (improved) and maintained their self-reported subjective units of distress rating. This measurement instrument will be administered on a regular basis, depending on the frequency of sessions.
They will have achieved consistent baseline scores on the outcome measures taken at the beginning of starting therapy and treatment. The outcome measure instruments assess depression, worry, anxiety, self-esteem, trauma, childhood experiences, life events, addiction, substance abuse, chemical dependence, gambling problems, eating disorders, and many others.
They will have improved their rating score of satisfaction in most or all of their health, wellness, and life domains (relationships, family, friends, school, work, recreation, exercise, nutrition, sleep, activity, gender, sex) and other domains (physical, cultural, spiritual, political, environmental, and educational).
The client will have increased their level of functioning in most or all of their daily activities of living, and have achieved an acceptable level of satisfaction and functioning in the following areas: daily activities of living, household responsibilities, cleaning, personal hygiene, living space organization, home safety, and home maintenance tasks; Important relationships, (intimate, romantic, sexual, occupational, community, family, friends, peers); worlds of occupation, education, and/or volunteering; areas such as, physical health, nutritional, financial, social, cultural, and environmental.
The client will have resolved the core conflict that is the source of any symptoms, memories, nightmares, and/or resulting behaviors, related to their diagnoses.
They will have enhanced their ability to effectively cope with the full variety of life’s problems, stressors, worries and anxieties.
They will have learned and implemented coping skills that result in a reduction of client’s reported and observed symptoms, behaviors, and problems, related to their diagnoses.
They will have alleviated their symptoms and returned to previous level of effective functioning.
They should now recognize, accept, and cope with feelings.
They will have developed positive schema, thinking patterns and beliefs about self, others, and the world that have led to the alleviation of, and helped prevent relapse of, symptoms and behaviors.

The client’s reported long-term goals
* listed here, in their own words

THE ACTIVITIES DESCRIBED HERE ARE APPLICABLE TO ALL CLIENTS

They may not relate to each client’s specific individualized goals. Only those chosen by the client and completed will be recorded in the client’s chart.
The client’s stated long-term goals for therapy will be listed in the electronic record, quoted directly from the client in their own words.
The long-term goals for therapy from the specific treatment plans will be listed in the elctronic record, referenced directly from the treatment planner books.

Consultation, Intake, Assessment, and Diagnosis

The Scheduling Process

The tasks in this section should have been completed before the treatment plan was cooperatively created. The client was sent the following documents prior to scheduling the intake appointment and has completed or reviewed and signed.

The clinician’s intake process, compliance procedures, and instructions for completing the packet of documents.
The clinician’s professional public disclosure statement for LCMHC. (new statement sent every year)
The Vermont Secretary of State Office of Professional Regulation statutes & professional regulations document
The clinician’s philosophical and theoretical orientation document.
The clinician’s ethical compliance and accountability statement.

The client was asked to carefully and thoroughly review the counselor’s website, exploring the following pages. The pages most relevant to the consultation, intake, and onboarding paperwork, processes, and sessions.

The Client’s Medical Records Chart Documents Process

Client History Form
Client Information Form
Client Insurance Form
Payment Authorization Form
Notice of Privacy Practices (new form sent every year)
Emergency & Other Contacts Form
Authorization to Use or Disclose Protected Health Information

The documents and forms in this section should have been completed before the treatment plan was cooperatively created. The client was asked to complete the following documents and forms on or before the day of the intake appointment. Some of the documents listed are all included in the first item, a required form in the client account portal, and presented seperately on this website.

Therapy Agreement and Informed Consent to Treatment (Form)
- Policies and Procedures
- Consent for Electronic Communication
- Consent for Telehealth Sessions
- Consent for AI Transcription and/or Dictation of Sessions
- No Surprises Act: Good Faith Estimate
- Medicare Coverage – Advance Beneficiary Notice
Prescribed Medications Vitamins and Supplements
Terms & Conditions of Use and Copyright Content Disclaimer
Library of Documents and Forms – Table of Contents
Consent for Services (Form)

The Consultation & Intake Sessions

Prior to the consultation session, the clinician will email the client an invitation to register in the client account portal. Once the client has registered, the clinician will send the client his public disclosure statement, notice of privacy practices, and the Office of Professional Regulation Vermont Statutes for Licensed Mental Health Counselors.

The Consultation Session

Prior to the intake session, the clinician will verify that the client has completed all the required paperwork, and/or watched all the videos; and will reinforce and reassign the documents and videos as homework before the next session. The clinician will complete the paperwork in session that needs to be done to stay in compliance.

The intake session will adhere to the following format:

Review a summary of the clinician’s experience, education, training, credentials.
Discuss the client’s presenting problem: what brings them to therapy
Discuss important policies, procedures, session format, mental capacity, medical necessity, and compliance process.
Discuss the treatment planning process, progress notes, and the HAq-II: The Revised Helping Alliance Questionnaire
Schedule a set of sessions to build rapport, gather more history, and develop trust.

The Intake Process

The client and clinician will review this document for clinician transparency and accountability, so the client is involved in the treatment planning process. After the intake session, the clinician will send client the following forms and assign the homework below. Each topic listed has the following resources: a website page; a Quenza pathway; a PDF copy; and a Client Account Portal form.

Comprehensive PHQ: Patient Health Questionnaire

The Patient Health Questionnaire (PHQ) is a comprehensive screening tool designed to effectively recognize and assess common mental health disorders, including but not limited to mood disorders, anxiety disorders, alcohol use disorders, eating disorders, and somatoform disorders. By utilizing standardized questions, the PHQ not only identifies the presence of these conditions but also evaluates their severity, providing valuable insights to healthcare providers. This enables practitioners to tailor treatment plans based on an individual’s specific needs, ensuring that patients receive appropriate care and support. Furthermore, the PHQ has been widely validated across diverse populations, making it a reliable instrument in both clinical and research settings. Additionally, its user-friendly format encourages patients to openly discuss their mental health concerns, fostering a more transparent and productive dialogue between them and their healthcare providers. Completing the questionnaire should take less than 10 minutes. This assessment can be done in session or assigned to the client as homework. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

Review the Questions you will be asked

Rule Out Medical Conditions

When it is appropriate and necessary, the clinician and client will work together to schedule an appointment for a physical health examination, ensuring that both parties have ample opportunity to discuss any specific concerns or symptoms that may exacerbate mental health challenges. This collaborative approach not only empowers the client to actively participate in their mental health care but also allows the clinician to better prepare for the sessions by understanding the client’s unique health history and needs. By establishing a clear timeline for the appointment, the clinician can also ensure that all necessary information and resources are available, thereby facilitating a more thorough and efficient therapy process.

The client will complete a medical evaluation from a physician, to assess for any possible contribution of neurological, medical, or substance-related conditions to the symptoms and behaviors associated with their presenting problems. If being treated by (or has been treated by) their physician, discuss and process any medical concerns, illness, disease, chronic pain, or physical health and wellness problems and goals with clinician. The clinician will provide a referral to a physician for a medical evaluation and physical health examination to rule out general medical or substance-related causes of their presenting problems. The clinician will discuss and process medical concerns, illness, disease, chronic pain, or physical health and wellness problems and goals, with the client. The clinician will provide encouragement, support, and person-centered, strengths based guidance.

Assess the Need for Psychiatric Medication

When it is appropriate and necessary, the mental health counselor and client will work together to schedule an appointment for a medication evaluation by a physician or psychiatrist, ensuring that the client feels supported throughout the entire process. This collaboration involves discussing the client’s needs, preferences, and any concerns they may have regarding medication management. The counselor will provide information on what to expect during the evaluation, including the types of assessments that may be conducted and the importance of open communication with the prescribing physician. By fostering a trusting environment, the counselor and client can clarify the goals of the evaluation and the potential benefits it might bring to the client’s overall mental health and well-being.

The client will cooperate with and complete a – neurological, educational, social, emotional, mental/cognitive, speech, language, communication – physical and psychiatric evaluation to rule out medical and substance related etiologies and assess the need for psychotropic medication. If currently prescribed medication to alleviate symptoms and problems, discuss medication compliance and any resistance or ambivalence, ask for accountability from the clinician, and discuss side effects and efficacy of medications. The clinician will arrange for and provide a referral for a – neurological, educational, social, emotional, mental/cognitive, speech, language, communication – physical and psychiatric evaluation to rule out medical and substance related etiologies and assess the need for psychotropic medication. The clinician will assist client with remaining compliant and taking medication as prescribed by regularly assessing medication compliance, side effects, and efficacy. They will confer regularly with the client’s prescribing physician.

Client Intake Assessment for Integrative Care

When it is appropriate and necessary, the mental health counselor and client will collaboratively engage in a thorough discussion to schedule an appointment aimed at screening for various problems and barriers that may lie outside the clinician’s scope of practice. This process is crucial as it enables both parties to identify any underlying issues that may affect the client’s mental well-being and overall health. During the appointment, they will assess the client’s needs comprehensively to determine if a higher level of care is warranted, ensuring that the client receives the most suitable support and guidance for their situation. This collaborative approach not only fosters a stronger therapeutic alliance but also empowers the client to be actively involved in their treatment journey.

Arrange a client’s Psychiatric/Neuropsychological Evaluation: Ensure all necessary documentation is collected, coordinate with the client regarding scheduling, prepare the client for the evaluation by explaining the process, and confirm that all relevant medical history and previous assessments are available for the evaluator’s review.
Arrange a client’s Psychometric Testing for Intelligence Scores. Verify that all necessary resources and tools are prepared in advance to facilitate a smooth assessment process.
Arrange Substance Use Testing for the client (Urinalysis and Breathalizer): This involves coordinating with a local testing facility to ensure that the client undergoes both urinalysis and breathalyzer tests in a timely manner, facilitating their participation in any required treatment programs or court-ordered evaluations.
Arrange an Intake appointment for the client with a Community Treatment Program with a VT Designated Mental Health Agency: Gather all necessary documentation and obtain consent forms from the client prior to the meeting to facilitate a smooth process.
Arrange a referral to consultation with a nutritionist for Eating Disorder Treatment for the client to discuss their specific needs in depth, thoroughly assess their unique situation, and collaboratively develop a tailored treatment plan that addresses their individual challenges and personal goals, ensuring a comprehensive understanding of their dietary requirements and emotional triggers for a more effective recovery process.
Arrange a referral to consultation for Intensive Outpatient Treatment (a higher level of care) that involves comprehensive assessments, individualized treatment plans, and regular follow-up sessions to ensure optimal support and recovery for the individual in need.
If required and appropriate, encourage the client to reach out to crisis services for emergency care, inpatient rehabilitation, or inpatient hospitalization (a higher level of care) after conducting a thorough risk assessment, taking into consideration all relevant factors affecting the client’s well-being, and develop a comprehensive safety contract that clearly outlines the steps to be taken for ongoing support and monitoring.

Intake Screening Sessions

The clinician will thoroughly assess for, and the client will provide comprehensive behavioral, emotional, and attitudinal information related to: a detailed assessment of specifiers relevant to both the primary and co-occurring DSM diagnoses, based on an in-depth exploration of the problems, symptoms, and behaviors presented by the client; the careful creation, implementation, and necessary revisions of the treatment plan to ensure it remains aligned with the evolving needs of the client; the diligent tracking of treatment outcomes over time to evaluate progress and effectiveness; the ongoing support of the efficacy of therapy and treatment interventions through consistent feedback and analysis; and the important process of building rapport and trust, which serves to enhance and deepen the nature of the therapeutic relationship, ultimately fostering a safe and supportive environment where meaningful change can occur.

The clinician will assess the client’s level of insight (syntonic versus dystonic) toward the “presenting problems.” This assessment is crucial as it helps to determine how well the client understands and acknowledges their issues. Does the client demonstrate good insight into the problematic nature of the “described behavior,” agree with others’ concern, and are they motivated to work on change? If the client shows an eagerness to comprehend their actions and the implications they have on their life and relationships, this is a positive indicator. However, does the client demonstrate ambivalence regarding the “problem described” and are they reluctant to address the issue as a concern? This ambivalence can often lead to a stalemate in the therapeutic process, where progress is hindered by the client’s uncertainty. Finally, does the client demonstrate resistance regarding acknowledgment of the “problem described,” indicating they are not concerned, and they have no motivation to change? Such resistance poses a significant challenge, requiring thoughtful and strategic intervention. The clinician will use motivational interviewing strategies to assess the current stage of change effectively, exploring the client’s feelings and attitudes while encouraging an increase in motivation. Building rapport during this process is essential, as is the integration of Socratic dialogue communication skills, which allow for a guided exploration of the client’s thoughts, beliefs, and behaviors, fostering deeper insight and understanding.

The clinician will: assess for evidence of research-based correlated disorders, including vulnerability to suicide, if appropriate, by reviewing the client’s history, previous diagnoses, and any documented risk factors; assess for any issues of age, gender, or culture that could help explain the client’s currently defined “problem behavior,” recognizing that these factors may influence treatment approaches; assess for any factors that could offer a better understanding of the client’s behavior—such as environmental stressors, family dynamics, or significant life events—while taking the time to build rapport; assess for the severity of the level of impairment to the client’s functioning to determine the appropriate level of care by utilizing standardized assessment tools and clinical interviews; does the behavior noted create mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors, considering the impact on the client’s daily life and long-term goals; continuously assess this severity of impairment as well as the efficacy of treatment through ongoing evaluations and feedback from the client; does the client no longer demonstrate severe impairment but the presenting problem now is causing mild or moderate impairment, necessitating a re-evaluation of treatment strategies to ensure that the client receives the most effective support moving forward.

The client will disclose any current use or history of heavy alcohol and/or substance use that may contribute to and complicate the client’s treatment of their presenting problems, as this information is essential for developing an effective treatment plan. It is crucial for the therapeutic process that the client openly shares any patterns of dependency, including the frequency, quantity, and consequences of their substance use, as well as any previous attempts at rehabilitation or interventions. Understanding these factors allows the therapist to tailor their approach, ensuring that the client receives comprehensive support that addresses not only their immediate concerns but also the underlying issues connected to substance use, which can significantly impact their overall mental health and wellbeing.

The clinician will carefully assess whether a higher level of care is needed, taking into account the specific circumstances of the client and referring to the established guidelines set forth by the ASAM and SAMHSA criteria. If the assessment indicates a need for more intensive intervention, the clinician will not only arrange for but also provide a thorough referral for a comprehensive substance abuse evaluation. This evaluation is crucial as it informs the next steps in the client’s treatment process. Based on the results of the evaluation, the clinician will ensure that the client is referred to appropriate treatment options, which may include intensive outpatient programs, residential rehabilitation centers, or inpatient treatment facilities. Each of these options is tailored to meet the unique needs of individuals struggling with substance abuse, and the clinician will work diligently to connect the client with the most suitable resources available to foster their recovery journey.

Additional Assessment Instruments

The client will read the Overview of Assessments, which provides a comprehensive insight into the various types of evaluations that will be conducted. This document outlines the objectives of each assessment, the methodologies employed, and the expected outcomes, ensuring that the client gains a thorough understanding of the assessment process and its importance in achieving the desired goals. Additionally, it will highlight key areas of focus and offer guidance on how to interpret the results effectively.

They will complete the following homework assignments:

Client will read the introduction, which provides a comprehensive overview of the objectives and goals of the assessment process, and then proceed to complete the Biopsychosocial Assessment, a crucial step that evaluates various aspects of their well-being, including biological, psychological, and social factors that influence their health.

Client will read the introduction thoroughly to gain an understanding of the assessment framework, and then will proceed to complete the Broad Range Comprehensive Biopsychosocial Assessment, which encompasses a detailed evaluation of psychosocial factors, biological influences, and individual psychological contexts. This comprehensive assessment is crucial for identifying the various elements that contribute to the client’s overall well-being, making it an essential component in developing a tailored support plan that addresses their unique needs and circumstances.

Client will read the introduction thoroughly to understand the objectives and importance of the process ahead, and will subsequently complete the Values Questionnaire (Strengths Exploration), which is designed to identify and articulate their inherent strengths and values. This questionnaire serves as a foundational tool that will guide them in reflecting on their past experiences and recognizing the unique qualities they possess, ultimately helping to enhance personal growth and align their future decisions with their core values.

Outcome Measures

Based on the screening and intake paperwork, conduct the following tests and assessments only when applicable to each client. Conduct regular completion of follow up assessments using the measures, to be used to measure treatment effectiveness.

ACE: Adverse Childhood Experiences Questionnaire: A tool used to assess the impact of childhood trauma and stress on individual development and mental health outcomes.
ASRS-v1.1: Adult ADHD Self-Report Scale: This is a comprehensive tool designed to help individuals assess symptoms of adult ADHD. The scale comprises a series of questions aimed at identifying potential symptoms and their impacts on daily life and functioning. By responding to these questions, clients can gain insights into their attention patterns, impulsivity, and overall behavior related to ADHD.
AWARE: Advanced Warning of Relapse Questionnaire is a comprehensive tool designed to identify potential relapses in individuals by assessing various psychological, emotional, and behavioral factors that may contribute to a relapse.
BBGS: Brief Biosocial Gambling Screen: The Brief Biosocial Gambling Screen (BBGS) is a concise questionnaire designed to help identify individuals who might be experiencing issues related to gambling. It includes a series of questions that assess a person’s gambling behaviors, motivations, and the impact of gambling on their daily life and responsibilities. This tool is beneficial for early detection and intervention strategies in gambling-related problems.
C-SSRS: Columbia-Suicide Severity Rating Scale (Screener, Recent) – a widely used tool designed to assess the severity of suicidal ideation and behavior in individuals, providing clinicians with valuable insights into the patient’s mental health status.
CUPIT: Cannabis Use Problems Identification Test: A comprehensive tool designed to assess and identify potential problems associated with cannabis use, allowing individuals to gain insights into their usage patterns and the impact on their daily lives, ultimately promoting awareness and encouraging responsible consumption practices.
DAS: Dyadic Adjustment Scale: A widely recognized measure used to assess the quality of a romantic relationship, evaluating various dimensions such as satisfaction, intimacy, and communication between partners.
DES-B: Adult Brief Dissociative Experiences Scale–Modified, which is a psychological assessment tool designed to evaluate the frequency and intensity of dissociative experiences in adults, providing insight into various symptoms related to dissociation and their impact on daily functioning.
DES II: Dissociative Experiences Scale II: This psychological assessment tool, known as the Dissociative Experiences Scale II, is designed to measure the frequency of dissociative experiences in individuals, providing insight into their psychological state and potential issues related to dissociation, which can manifest in various forms including depersonalization and derealization.
FTND: Fagerström Test For Nicotine Dependence, a widely used assessment tool for evaluating the level of dependence on nicotine, helps researchers and healthcare professionals understand the severity of addiction and guide treatment options.
GAD-7: Generalized Anxiety Disorder-7: A widely used screening tool for identifying generalized anxiety disorder and assessing its severity in individuals, helping healthcare professionals to understand the extent of anxiety symptoms and guide treatment options effectively.
LEC-5: Life Events Checklist for DSM-5: This checklist is a tool used in clinical settings to assess a range of life events that may contribute to an individual’s psychological well-being and mental health diagnoses. It includes various types of stressful experiences, such as loss, trauma, and significant life changes, providing a comprehensive overview of potential risk factors affecting the individual.
MDQ: Mood Disorder Questionnaire: A tool used by mental health professionals to help identify potential mood disorders through a series of questions aimed at assessing various symptoms and their impact on daily functioning, ultimately guiding further evaluation and treatment options.
OCI-R: Obsessive-Compulsive Inventory – Revised: This psychological assessment tool is designed to evaluate the presence and severity of obsessive-compulsive symptoms in individuals. It consists of a series of questions that help in identifying various OCD-related behaviors and thoughts, providing valuable insight for clinical evaluation and treatment planning.
PCL-5: PTSD Checklist for DSM-5: A self-report measure used to assess the presence and severity of PTSD symptoms as per the criteria laid out in the DSM-5, which includes a variety of questions aimed at understanding the impact of traumatic experiences on an individual’s mental health and functioning.
PHQ-9: Patient Health Questionnaire-9: An important screening tool used to assess the presence and severity of depression in patients, offering a self-administered format that can be easily integrated into routine medical practice.
PSWQ: Penn State Worry Questionnaire: This is a psychological assessment tool designed to measure the intensity and frequency of worry among individuals. It is widely used in research and clinical settings to examine generalized anxiety and related disorders. The questionnaire consists of multiple items that participants rate based on their experiences, providing valuable insights into their worry patterns and coping strategies.
RSES: Rosenberg Self-Esteem Scale: A widely used self-report instrument designed to measure self-esteem levels, developed by Dr. Morris Rosenberg in 1965. The scale includes items that assess an individual’s overall evaluation of their self-worth and serves as a valuable tool in psychological research and clinical practice.
SIAS: Social Interaction Anxiety Scale: The Social Interaction Anxiety Scale (SIAS) is a psychological tool designed to measure anxiety levels specifically associated with social interactions. It consists of a series of statements reflecting feelings and behaviors that individuals may experience in social situations, helping to identify and quantify the intensity of their anxiety. This scale is widely used in clinical settings as well as research to better understand social anxiety disorders and their impact on daily functioning.
TAPS: Tobacco, Alcohol, Prescription medications, and other Substance Tool: This tool is an essential resource that helps individuals assess their habits concerning tobacco, alcohol, prescription medications, and various other substances. It provides valuable insights and recommendations for making informed choices regarding substance use.
WHODAS: WHO Disability Assessment Schedule 2.0: A standardized instrument developed by the World Health Organization (WHO) that measures health and disability across different cultures and settings, providing insights into the functioning and well-being of individuals in daily life, with applications in various fields including health care, research, and education.

Diagnostic Clinical Examinations

Based on findings from screenings, intake process, assessments, and outcome measures, it is essential to complete the necessary clinical diagnostic examinations with the client to rule out or verify comorbid disorders that could complicate their treatment plan. Diagnosing serves a dual purpose: it helps to identify the nature of the client’s issues, thereby guiding effective interventions, while also sparking conversations around the controversy of labels and the associated stigma that can arise from them. This stigma can deter individuals from seeking help, as they may fear being defined solely by their diagnostic label rather than being seen as a whole person. To clarify the process, the DSM-5 TR—Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision—acts as a comprehensive guide that categorizes mental health disorders and outlines their symptoms in straightforward language, making it easier for both clinicians and clients to understand. However, it is important to recognize that not all of these criteria apply to every client; thus, the diagnostic process should be individualized, trauma-informed, and sensitive to cultural, social, and economic factors that may impact a client’s experience and understanding of their mental health. This approach ensures that clients feel respected and validated throughout their journey, fostering a therapeutic environment conducive to healing and growth.

Neurodevelopmental Disorders

The diagnosis of neurodevelopmental disorders involves a comprehensive evaluation of various factors, including behavioral assessments, developmental history, and standardized testing to identify specific conditions such as autism spectrum disorder, attention-deficit/hyperactivity disorder, and learning disabilities. Clinicians utilize a multifaceted approach that may include interviews with stakeholders, direct observation of the client’s behavior, and the application of diagnostic criteria established in manuals like the DSM-5. Early intervention is crucial, as it can significantly improve outcomes for affected individuals, highlighting the importance of accurate and timely diagnosis in supporting their developmental and educational needs.

Depressive & Mood Disorders

The diagnosis of depressive and mood disorders is a complex process that involves a comprehensive evaluation of an individual’s symptoms, medical history, and overall mental health. Clinicians typically use standardized assessment tools, interviews, and observational techniques to identify patterns that align with established diagnostic criteria, such as those found in the DSM-5 or ICD-10. This evaluation not only takes into account the severity and duration of mood changes but also examines the impact these disorders have on the individual’s daily functioning, relationships, and quality of life. Additionally, it is essential to rule out other possible causes of mood disturbances, including medical conditions, substance use, and situational factors, to ensure an accurate diagnosis. Early and accurate diagnosis is crucial for developing an effective treatment plan tailored to the unique needs of the individual, emphasizing interventions that may include psychotherapy, medication, or lifestyle modifications.

Anxiety Disorders

The diagnosis of anxiety disorders involves a comprehensive evaluation by mental health professionals, which typically includes a detailed clinical interview to assess symptoms, their duration, and the impact on daily functioning. Additionally, standardized assessment tools, such as questionnaires or scales, may be employed to quantify the severity of anxiety and to differentiate between various types of anxiety disorders, such as generalized anxiety disorder, panic disorder, or social anxiety disorder. Understanding the patient’s medical history, family history of mental health issues, and any concurrent stressors is crucial, as these factors can significantly contribute to the manifestation of anxiety. Furthermore, it’s essential to rule out any potential medical conditions or substance abuse that might lead to similar symptoms, ensuring that the diagnosis is accurate and the treatment plan tailored to the individual’s needs. Evaluating these elements aids in forming a holistic view of the patient’s mental health, ultimately guiding effective therapeutic interventions.

Obsessive Compulsive and Related Disorders

The diagnosis of obsessive compulsive and related disorders involves a comprehensive assessment that includes clinical interviews, standardized questionnaires, and careful observation of the patient’s behavior over time. These disorders are characterized by the presence of obsessions, which are intrusive and unwanted thoughts, images, or urges, and compulsions, which are repetitive behaviors or mental acts performed in response to these obsessions. It is essential for clinicians to differentiate between the various types of obsessive-compulsive disorders, such as hoarding disorder and body dysmorphic disorder, as each may require different treatment approaches. Furthermore, accurate diagnosis can lead to more effective therapeutic interventions, including cognitive behavioral therapy and medication, thereby significantly improving the quality of life for those affected.

Trauma and Stressor Related Disorders

The diagnosis of trauma and stressor related disorders is a complex process that involves a thorough assessment of an individual’s psychological and emotional state following exposure to traumatic events. These disorders can manifest in various forms, including but not limited to post-traumatic stress disorder (PTSD) and acute stress disorder, both of which require careful evaluation to ensure proper treatment. Clinicians utilize a combination of clinical interviews, standardized assessment tools, and patient history to identify symptoms that may include intrusive memories, heightened anxiety, emotional numbness, and avoidance behaviors. Understanding the context of the traumatic experience, along with the individual’s coping mechanisms and social support systems, plays a vital role in diagnosing these disorders effectively. Early detection and accurate diagnosis can significantly improve the prognosis and guide tailored therapeutic interventions, subsequently helping individuals to process their trauma and regain functionality in their daily lives.

Dissociative Disorders

The diagnosis of dissociative disorders is a complex process that involves a thorough assessment of the individual’s symptoms, history, and the context of their experiences. Clinicians typically utilize structured interviews and standardized questionnaires to identify key characteristics associated with dissociation, which can manifest as disruptions in memory, identity, consciousness, and perception. Furthermore, it is essential to differentiate these disorders from other mental health conditions that may present with similar symptoms, such as post-traumatic stress disorder (PTSD) or mood disorders. This careful evaluation process often requires collaboration with other healthcare professionals and may include a detailed review of the patient’s medical and psychological history to ensure an accurate diagnosis and effective treatment planning.

Sleep-Wake Disorders

The diagnosis of sleep-wake disorders is a complex process that involves a comprehensive assessment of the patient’s sleep patterns, behaviors, and overall health status. Health professionals often employ a combination of methods, including sleep studies, questionnaires, and patient interviews, to gather essential information. Common sleep-wake disorders include insomnia, sleep apnea, restless legs syndrome, and circadian rhythm disorders, each presenting unique challenges and symptoms that can significantly affect daily functioning and quality of life. Accurately diagnosing these disorders is crucial, as effective treatment plans can drastically improve sleep quality and address related health issues. Moreover, understanding the underlying causes, such as stress, lifestyle choices, or medical conditions, is vital to developing a holistic approach to treatment and management.

Disruptive, Impulse-Control, and Conduct Disorders

The diagnosis of disruptive, impulse-control, and conduct disorders is a crucial aspect of mental health evaluation, as these conditions can significantly impact a person’s ability to function in social, academic, and occupational settings. These disorders encompass a range of behavioral issues characterized by persistent patterns of behavior that violate societal norms or the rights of others. The process of diagnosing these disorders typically involves a comprehensive assessment that includes clinical interviews, behavioral observations, and standardized rating scales to differentiate between various conditions, such as oppositional defiant disorder and conduct disorder. Early identification and intervention are essential, as effective treatment strategies can lead to improved outcomes, enabling individuals to develop healthier coping mechanisms and interpersonal skills. It is essential for healthcare providers to approach these diagnoses with sensitivity and an understanding of the complex interplay between biological, environmental, and psychological factors that contribute to the development of disruptive behaviors.

Substance-Related and Addictive Disorders

The diagnosis of substance-related and addictive behaviors is a complex process that requires thorough assessment and evaluation by trained professionals. This diagnosis not only considers the physical and psychological symptoms exhibited by the individual but also takes into account the social and environmental factors that may contribute to the addiction. Various diagnostic tools and criteria, such as those outlined in the DSM-5, assist clinicians in identifying the severity and nature of the substance use disorder. Additionally, understanding the patient’s history, including any co-occurring mental health issues, plays a crucial role in forming a comprehensive treatment plan tailored to the individual’s unique circumstances. Early diagnosis and intervention can significantly impact the effectiveness of the treatment and the individual’s journey towards recovery.

SNAP+V Assessment

In a therapy treatment plan, understanding the client’s strengths, needs, abilities, preferences, and values is crucial. This information helps to create a personalized therapeutic approach. By including these factors in the treatment plan, therapy becomes more engaging and satisfying, leading to better outcomes. Tailoring therapy to each individual allows practitioners to support clients in reaching their goals and enhancing their quality of life.

During the initial sessions, the client will provide additional information about themselves, as much as they are able to share their strengths, needs, abilities, preferences, and values. This information will benefit the process of therapy and their treatment.

The clinician will administer to the client, an assessment of their strengths, needs, abilities, preferences, and values. The assessment will be used to collaboratively set specific, measurable, achievable, relevant, and time-bound goals, ensuring they are broken down into smaller, manageable tasks. The clinician will tailor interventions to capitalize on the client’s strengths, address their needs, and respect their preferences. This may include organizational tools, behavioral strategies, and mindfulness practices. The clinician will regularly review and adjust the treatment plan based on the client’s progress, ensuring strategies remain effective and aligned with their evolving strengths, needs, and preferences.

STRENGTHS

Identifying and leveraging a client’s strengths can empower them and build confidence throughout the therapeutic journey. Utilizing the following strengths fosters a collaborative environment, enhances engagement, and provides a solid foundation upon which to build new skills and strategies.

Resilience: The ability to bounce back from adversity can help clients navigate challenges during therapy.
Motivation to Change: A desire to improve encourages active participation and commitment to the treatment plan.
Supportive Relationships: Friends and family can provide emotional support and reinforce positive changes.
Effective Communication Skills: Being able to express thoughts and feelings aids in transparency and understanding.
Positive Coping Mechanisms: Existing healthy strategies can be built upon to manage stress and emotions.
Self-Awareness: Insight into one’s behaviors and patterns facilitates deeper work in therapy.
Problem-Solving Skills: Ability to identify solutions can accelerate progress toward goals.
Past Successes: Previous achievements in overcoming difficulties can inspire confidence in the therapeutic process.

The client will add any additional strengths they feel are important to them, in their own words. The clinician will add the client’s statement to their treatment plan.

NEEDS

Addressing a client’s specific needs ensures that the treatment plan is relevant and effective. Meeting the following needs removes barriers to progress, allows for personalized interventions, and supports overall mental health and well-being.

Safety and Stability: Establishing a secure environment is fundamental for therapeutic work.
Emotional Support: Regular encouragement helps clients feel valued and understood.
Skill Development: Learning new coping strategies and life skills addresses gaps that hinder progress.
Education on Mental Health: Understanding their condition empowers clients to take an active role in their recovery.
Social Support Networks: Building connections reduces isolation and promotes well-being.
Autonomy and Empowerment: Encouraging self-efficacy enhances motivation and adherence to the treatment plan.
Attention and Focus: Strategies to improve concentration and manage distractibility.
Organization: Tools and techniques to help with planning, time management, and staying organized.
Impulse Control: Methods to manage impulsivity and improve decision-making.
Emotional Regulation: Support in managing strong emotions and stress.
Behavioral Needs: Modifying disruptive behaviors and developing positive habits.

The client will add any additional needs they feel are important to them, in their own words.. The clinician will add the client’s statement to their treatment plan.

ABILITIES

Acknowledging a client’s abilities allows for the optimization of therapeutic techniques. Leveraging the following abilities maximizes the effectiveness of interventions and accelerates the achievement of therapeutic goals.

Reflective Thinking: Capacity for introspection aids in processing experiences and emotions
Building Therapeutic Alliance: Ability to establish trust enhances collaboration and openness.
Cognitive Functioning: Mental acuity supports the understanding and application of therapeutic concepts.
Communication Proficiency: Expressing oneself clearly facilitates effective dialogue.
Engagement in Therapy: Active participation contributes to meaningful progress.
Hyperfocus: The ability to concentrate intensely on tasks of great interest, which can be harnessed productively.
Quick Thinking: Fast and dynamic thinking patterns that can be channeled constructively.
Task Switching: The ability to handle multiple tasks simultaneously, when appropriately managed.
Adaptability: Flexibility in adapting to new situations or changes in routine.
Social Skills: Potential strengths in engaging with others and building relationships, despite occasional social challenges.

The client will add any additional abilities they feel are important to them, in their own words.. The clinician will add the client’s statement to their treatment plan.

PREFERENCES

Respecting a client’s preferences increases satisfaction and engagement with the therapy process. Incorporating the following preferences leads to greater adherence to the treatment plan and a more personalized therapeutic experience.

Therapeutic Approaches: Favoring certain modalities (e.g., CBT, mindfulness) can enhance receptiveness.
Therapist Characteristics: Comfort with specific traits (e.g., gender, cultural background) fosters trust.
Session Format: Choosing between individual or group therapy, in-person or virtual sessions, impacts accessibility and comfort.
Pace and Structure: Aligning the tempo and organization of sessions with client preferences ensures they feel in control.
Session Structure: Shorter, more frequent sessions may be preferred to maintain focus and engagement.
Goals and Outcomes: Clear, realistic goals that are broken down into manageable steps.
Communication Style: A preference for direct, clear, and supportive communication with frequent feedback.

The client will add any additional abilities they feel are important to them, in their own words. The clinician will add the client’s statement to their treatment plan.

VALUES

Understanding and integrating a client’s values ensures that therapy is meaningful and relevant. Aligning interventions with the client’s values ensures relevance, promotes internal harmony, and sustains long-term change.

Family and Relationships: Emphasizing these areas can motivate change and support.
Cultural and Religious Beliefs: Respecting these principles fosters respect and understanding.
Personal Ethics: Aligning therapy with values like honesty and integrity reinforces authenticity.
Importance of Mental Health: Valuing well-being encourages commitment to the process.
Life Goals and Aspirations: Connecting therapy to broader objectives enhances motivation.

The client will add any additional values they feel are important to them, in their own words. The clinician will add the client’s statement to their treatment plan.

Treatment Planning Stage:

Treatment Plan Development

The client will complete each of the portal forms (activities and lessons) listed below. The clinician will continue producing videos to offer clients that detail the information in each activity. The client and clinician will review the treatment plan stored in the client’s chart on the client account portal.

Treatment Planning Overview (This page)
Introduction to Strengthening Your Conscious Self
The Health & Wellness Domains
The Integrated Approaches
Treatment Plan Review
Taking Action Toward Change
Why Do We Need A Treatment Plan?
How do clinicians develop treatment plans?
What is a presenting problem?
What is a symptom?
What is a long term goal?
What are objectives and interventions?
Setting Process Goals and SMART Goals
Self Assessment of Presenting Problems
Exploring The Benefits of Change
Client Chosen Problems and Goals
Client Goals for Specific Problems (with examples)
Developing Your Health & Wellness Plan
Developing Your Best Structured Daily Routine

Choosing the Objectives & Interventions from the Universal Treatment Plan

This stage of therapy with the clinician might take up to 3 sessions to complete. The client and clinician will review the complete therapy program, assess the client’s presenting problem and long-term goals, and discuss their unique circumstances, mental capacity, strengths, needs, abilities, preferences, values, ideology, cultural/social influences, and worldview. The client will choose specific goals, objectives, and interventions detailed in the universal therapy treatment plan stored in the patient chart on the Therapy Notes Client Account Portal. They will work with clinician to complete the objectives and interventions outlined in the therapy planner.

The clinician will help client choose and participate in evidence based therapeutic interventions that include but are not limited to mindfulness skills and meditation education, critical thinking skills training, emotional regulation skills training, distress tolerance techniques application, and interpersonal effectiveness and emotional intelligence classes. They will help client choose and participate in evidence based therapeutic interventions that include the Internal Family Systems, to be used for achieving a state of wise mind, healing past burdens, for a balanced and integrated system of parts, led by self energy. They will help the client to heal, develop life skills, and improve their best self, and exhibit the character strengths of honesty, empathy, humility, commitment, compassion, connection, presence, consideration, calm, patience, content, clarity, playfulness, curiosity, perception, creativity, cooperation, persistence, courage, and confidence. They will support the client by encouraging and supporting the client’s practice of therapeutic interventions.

Choosing the Objectives & Interventions from the Leahy Treatment Planner Book

The client will choose specific goals, objectives, and interventions adapted from Treatment Plans and Interventions for Depression and Anxiety Disorders, 2nd ed. (Leahy, Holland, McGinn). The plans derived from this book are included in the Therapy Program, stored in the patient’s medical records chart on the Therapy Notes Client Account Portal. The client will work with clinician to complete the objectives and interventions outlined in the therapy plans.

The clinician will help choose and provide evidence based therapeutic interventions that include but are not limited to mindfulness skills and meditation education, behavioral interventions, cognitive interventions, and relapse prevention skills. They will support the client by encouraging and supporting the client’s practice of therapeutic interventions outlined in the plans.

Choosing the Objectives & Interventions from the Wiley Publishing Treatment Planner Series

The client will choose specific goals, objectives, and interventions adapted from the problem specific Wiley Publishing Treatment Planner series treatment plans. review, sign, and date the plan (stored in the patient’s medical records chart on the Therapy Notes Client Account Portal) They will work with clinician to complete the objectives and interventions outlined in the therapy plans.

The clinician is providing access to the plans available to the client; addressing specific problems which include but are not limited to: childhood trauma, post traumatic stress disorder, attention deficit with hyperactivity, panic attacks, social anxiety, depression, complex grief, bipolar and mood disorders, chemical dependence, substance use disorders and addiction, maladaptive personality styles, anger management, sexual dysfunction, interpersoanl relationship problems, and generalized anxiety. They will hold fidelity to and adhere to an integrative and holistic approach to therapy that is informed by mind-body, mindfulness-based, and empirically supported interventions addressing: cognitive, emotional, physical, intellectual, social, cultural, and environmental domains of the client’s life.

Objectives & Interventions

There is a separate page with the objectives and interventions listed.

View the Objectives & Interventions

Discharge Criteria/Planning

The client may use the following guidelines to help them determine when therapy is no longer needed. The client may decide to end therapy when both the client and therapist agree that therapy has been successful, and the client feels ready to end the therapy process. They may decide to end therapy when there is a clear plan for the transition, including strategies for maintaining gains, managing potential setbacks, and criteria for seeking therapy in the future if needed.

The client agrees to end therapy after they have achieved the primary goals set at the beginning of therapy. These could include symptom reduction, behavior change, or improved coping strategies. Improvements are not only achieved but maintained over time, indicating sustainable change.
The client agrees to end therapy when they have a solid relapse prevention plan, including managing triggers, recognizing warning signs, applying coping strategies, and knowing when and how to seek help.
The client agrees to end therapy when there are clear steps and resources identified for crisis situations, ensuring the client feels prepared to handle emergencies independently.
The client may end therapy at any time if they feel like therapy with their clinician is not bringing them closer to their goals, and/or they feel that the therapist is not a right fit for them.
The client agrees to end therapy when they have consistently demonstrated the ability to use effective coping strategies learned in therapy to deal with stress, anxiety, and other emotional challenges.
The client agrees to end therapy when there is evidence of the client’s ability to manage symptoms independently, without relying on therapy as the primary coping mechanism.
The client agrees to end therapy when there’s a significant reduction in the severity and frequency of symptoms that led the client to seek therapy.
The client agrees to end therapy when the client shows improved functioning in daily activities, relationships, and occupational roles.
The client agrees to end therapy when the client has gained insight into their thoughts, emotions, and behaviors, understanding the underlying patterns and triggers.
The client agrees to end therapy when there is a clear sense of personal growth and development, with an enhanced understanding of self-identity and values.
The client agrees to end therapy when the client’s life circumstances are stable enough to support discharge, including stable housing, employment, and social relationships.

Other Criteria for Discharge or Termination of Services:

There is a comprehensive assessment of the client’s progress, including feedback from the client about their therapy experience.
A follow-up schedule is agreed upon, if necessary, to check on the client’s well-being post-discharge, allowing for adjustment of the discharge plan as needed.
There is a robust support system in place, including friends, family, or community resources, which the client can utilize when faced with challenges.
The clinician has recorded a termination session note and discharge summary. The clinician has drafted and emailed a termination letter and summary of therapy progress to the client.
The clinician may decide to terminate services if it is determined that the client needs a higher level of care. This process will be documented carefully and thoroughly.
The clinician may decide to terminate services if the client has missed 3 consecutive sessions and there has been no contact between client and clinician.
The clinician may decide to terminate services if their are serious safety issues that cannot be addressed without interventions from third parties, emergency services, or designated agencies.

Attestation & Commitment

Frequency of Treatment

The prescribed frequency of treatment typically starts with weekly sessions. Frequency is influenced by many factors, including but not limited to financial matters, sechedules, work and school, child care and family, and insurance justification. After some time has elapsed, the client and clinician may agree to less frequent sessions. The frequency will be noted in the treatment plan and recorded on every progress note.

Signatures

I will indicate on the actual plan that I declare that these services are medically necessary and appropriate to the recipient’s diagnosis and needs. I will sign the actual form with the following attestation: I, James Fitzgerald, Licensed Mental Health Counselor, License VT 068.0135266, declare this information to be accurate and complete. The client (you) will also be required to sign the actual treatment plan, per licensing regulations, and insurance policies.

If you would like to see exactly how the treatment plan and progress note appears in the Therapy Portal client’s record, click the bttuons.

The Treatment Plan

The Progress Note