- The client has been diagnosed with a principal clinical disorder and secondary/tertiary disorders based on DSM-5 criteria. - The treatment plan outlines short-term goals and measurable objectives related to improving the client's social/emotional functioning, as well as interventions for the client, therapist, mental health coach, teacher, and family. - Progress will be measured regularly and the treatment plan will be updated accordingly.

1. Client’s main presenting problems/ symptoms (Include client report as well as teacher, parent & clinician observation/testing. Please be specific & include significant
events):
Progress made since last treatment plan:
A physician has ruled-out a medical basis for the client’s symptoms? Yes No If no, why?
DSM-5 Diagnosis: Clinical Disorder(s) and other conditions that may be a focus of clinical attention.
Diagnostic Code Disorder Name
Principal Diagnosis:
Subtypes & Specifiers: Severity:
Diagnostic Criterion:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Diagnostic Code Disorder Name
Secondary Diagnosis:
Subtypes & Specifiers: Severity:
Diagnostic Criterion:
Diagnostic Code Disorder Name
Tertiary Diagnosis:
Subtypes & Specifiers: Severity:
Diagnostic Criterion:
Medication Regimen
No Prescribed Medication
Physician Name
Physician Contact #:
Medication Dosage Range Time(s) of Day Consent (Yes/No)
1.
2.
3.
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TREATMENT
PLAN
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Report Date:
Client Name (last, first):
DOB: Gender: Click here Admit Date:
IEP Date: Semi-annual Tx Plan Date:
Program: School:
Therapist:
Teacher:

2. 4.
5.
Service Discipline Frequency
Individual Therapy
Licensed MHP (PhD., PsyD, LCSW, MFT)
Qualified MHP (ACSW, MFT Intern, Professional Counselor Intern)
Group Therapy LMHP QMHP
Family Therapy LMHP QMHP
Milieu Services LMHP QMHP Behavior Coach As needed
Collateral Services LMHP QMHP Behavior Coach As needed
Crisis Intervention LMHP QMHP Behavior Coach As needed
Other, specify:
Discharge Planning
Therapist’s Name:
Signature: Date:
Supervisor’s Name:
Signature: Date:

3. Student’s main presenting problems/ symptoms (Include student report as well as teacher, parent & therapist observation/testing. Please be specific & include
significant events):
Progress made since last treatment plan:
Student & Family Strengths (What will be used to help the student achieve their treatment plan goals & measurable objectives? Include student report as well as teacher,
parent & therapist observation. Please be specific.)
Diversity Issues & Considerations
Long Term Goals
Short Term Goals
Measurable Objectives
Social/Emotional Objective #1: …XX% of the time.
By: ??/??/????
Current Functioning: % of the time. As of: ??/??/????
Progress made since last treatment plan:
Therapist
Interventions:
1.
2.
3.
Mental Health
Coach
Interventions:
1.
2.
3.
Teacher
Interventions:
1.
2.
3.
Student
Interventions:
1.
2.
3.
Social/Emotional Objective #2: …XX% of the time.
By: ??/??/????
Current Functioning: % of the time As of: ??/??/????
Progress made since last treatment plan:
Therapist
Interventions:
4.
5.
6.
Mental Health
Coach
Interventions:
4.
5.
6.
Teacher
Interventions:
4.
5.
6.
Student 4.

4. Interventions: 5.
6.
Social/Emotional Objective #3: …XX% of the time.
By: ??/??/????
Current Functioning: % of the time As of: ??/??/????
Progress made since last treatment plan:
Therapist
Interventions:
7.
8.
9.
Mental Health
Coach
Interventions:
7.
8.
9.
Teacher
Interventions:
7.
8.
9.
Student
Interventions:
7.
8.
9.
Old Objectives (What objectives have you worked on with the student in the past and what were the results?)
Family Goals
Progress made since last treatment plan:
Is the parent/guardian involved in the treatment of the student? Yes No
If not, why?
Was the parent/guardian involved in the creation of the treatment plan? Yes No
Does the parent/guardian agree with the treatment plan? Yes No
Parent/Guardian requested and received a copy of the Treatment Plan
Therapist explained benefits, alternatives, and risks or consequences of treatment.
SIGNATURES:
Student Name (Print):
Signature: Date:
Parent/Guardian (Print):
Signature: Date:
Therapist (Print):
Signature: Date:
Supervisor (Print):
Signature: Date: