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Treatment Plan #:
Client Name

Gender

Admit Date

Discharge Date

DOB

Goals, Strengths, Limitations

Goals (clients):
Strengths:
Limitations:

Problem (clinical interpretation of problem + client)

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

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Problem & Evidence

Long Term Goals

1.

2.

3.

Objectives for Long Term Goals

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

Target date

Achieved date

Problem 1:
Short Term Objective

Evidenced By

Problem 2:

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

Current Outcome

Date Achieved

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Short Term Objective

Evidenced By

Problem 3:
Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

Current Outcome

Date Achieved

Short Term Objective

Evidenced By

Discharge Criteria

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

Current Outcome

Date Achieved

Criteria:

Plan:

Support:

Diagnosis

Diagnosis changed

Diagnosis:

Medication

Medication changed

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

Medication

Reason

Safety Plan
Triggers:

Coping skills:

Summary

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW

Individual Therapy:

Narrative form of Overall Progress:

Adapted from Multi-Disciplinary Treatment Plan, Sarrah Gooch, LSW