So what exactly does a treatment plan contain? Whilst the information provided within your plans will largely depend on your client’s individual needs, we have compiled a list of some of the most essential components of an effective counseling treatment plan.
Demographics: Information regarding the patient’s demographics, including name, age, symptoms, medical history, and diagnosis.
Concerns: This section should explain the concerns that contributed to the patient seeking treatment. It may reiterate symptoms, determine when they began, and how they have impacted the client’s day-to-day life.
Contract: During the first session, the counselor and patient should create a “treatment contract”. This will state the health outcomes that the client is striving for, and propose how many sessions will be necessary.
Goals: The most important aspect of the treatment plan are the goals. You and your client should work together to create achievable target objectives for both short-term and long-term progress. In subsequent sessions, it is important to enquire whether the client has achieved these goals - celebrating small achievements is an important part of receiving treatment!
Interventions: As the counselor, it is essential that you detail the specific interventions and treatment methods that you have introduced to your client. These can be fluid, and you may come to realize that your original intervention isn’t as effective as you’d hoped, but it is important to document these changes.
Progress and outcomes: The improvement of an individual’s mental wellbeing needs to be measurable. By creating goals within your treatment plan, you will also be able to assess whether these have been achieved. At the end of your treatment process, you should be able to look back at your planning documents and identify specific achievements and overall health outcomes.
As you can see, the information contained within a treatment plan needs to be tailored to the client’s health needs. There are a variety of other important things you need to discuss with your client prior to treatment, including billing guides, insurance, and appointment information, but these conversations should happen externally to your treatment plan.