Case File Project

Treatment Plan Parts

CLIENT’S OVERALL GOAL/DESIRED OUTCOME

• The client’s desired outcome from successful treatment.

DIAGNOSIS/RECOVERY BARRIER/PROBLEM

• Primary Diagnosis’ signs/symptoms/impairments, and other barriers/challenges/problems.

Describes the behavioral health

symptoms and impairments that are the focus of treatment.

GOAL

• The removal or reduction of the problem, new replacement behaviors.

OBJECTIVE(S)

• What the client will do to reach the goal. S.M.A.R.T. (Specific, Measurable, Attainable,

Relevant, Time‐bound).

INTERVENTION(S)

• The specific services that staff will provide.

DURATION OF INTERVENTION

• 12 months. A Client Plan in which all interventions have a duration of less than one year must

be updated on time (before they

expire), prior to the annual due date.

FREQUENCY OF INTERVENTION

• Be specific (e.g., daily, weekly, etc.) or as a frequency range (e.g., 1‐4 x per month).

• Do not use terms such as “as needed” or “ad hoc”

Examples for Treatment Plans

Examples: DIAGNOSIS/RECOVERY BARRIER/PROBLEM

◦ Auditory hallucinations leading to self‐harm and hospitalization.

◦ Exhibits angry behavior in class; refuses to complete tasks or accept help; learning disabilities

impede progress in school.

Examples of Goals

◦ Reduce auditory hallucinations and improve symptom management.

◦ Get along better with others at school, without physical aggression.

◦ Will participate in job placement activities through Vocational Rehab Services (VRS).

Examples of Objectives

◦ From a baseline of 0, I will meet with MD 1x/month to discuss positive and negative impact of

medication over the next 12 months.

◦ Within 12 months, I will identify at least 2 activities, from a baseline of 0 activities, that will

help me not listen to negative voices.

◦ Within 12 months, I will have at least one friendly talk with peers 2‐3 times per week, from a

baseline of 0 friendly talks weekly.

Examples of Interventions

◦ Provide monthly medication support services to assess and monitor medication compliance,

client’s response and side effects.

◦ Provide rehab services weekly to assist client in performing ADLs and reducing anxiety.

◦ Provide targeted case management every 3 months, to coordinate with VRS, so client can

reduce depression and achieve employment goals.

◦ Will provide Individual Therapy 1x per week, for 6 months, utilizing Cognitive‐Behavioral

techniques, to assist client to reduce his anxiety.

◦ Case Management twice monthly, to ensure that client is utilizing support/resources to

maintain sobriety and address co‐occurring issues.

◦ DBT‐based individual therapy to reduce client’s self‐harming/cutting behaviors.