Mental Health Treatment Plan Template

Mental Health & Counseling

Treatment Plan

A structured framework for collaborative clinical care and measurable progress toward therapeutic goals.

Template Type Individual Therapy

Pages 3 pages

Client Information

Client Name: Jordan Ellis

Date of Birth: April 12, 1991

Client ID: 2024-0847

Plan Details

Clinician: Dr. Sarah Whitmore, LCSW

Start Date: March 17, 2026

Review Date: June 17, 2026

Session Freq: Weekly · 50 minutes

■ Confidential — Protected Health Information

Jordan Ellis

Client & Presenting Concerns

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Client Name Jordan Ellis

Primary Diagnosis Generalized Anxiety Disorder (F41.1)

Secondary Diagnosis Major Depressive Disorder, Mild (F32.1)

Referral Source Primary care physician — Dr. M. Torres

Insurance / Payer BlueCross PPO — Policy #789-045-22

Emergency Contact Alex Ellis (spouse) · (312) 555-0184

Chief Complaint Persistent worry, difficulty concentrating at work, disrupted sleep (averaging 4–5 hours/night), and increasing social withdrawal over the past 6 months.

Onset & Duration Symptoms began approximately September 2025 following a significant workplace restructuring. Client reports prior episode in 2019, resolved without formal treatment.

Strengths Strong motivation for change, supportive partner, stable employment, insight into patterns, prior positive coping strategies (exercise, journaling).

Treatment Goals & Objectives

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#	Goal	Objectives / Measurable Outcomes	Target	Status
1	Reduce anxiety severity to subclinical levels	GAD-7 score ≤ 7; client rates daily anxiety ≤ 3/10 on average across 2-week period	8 wks	Active
2	Improve sleep quality and duration	Sleep 6+ hours per night on 5 of 7 nights; implement sleep hygiene protocol consistently for 4 weeks	6 wks	Active
3	Build cognitive restructuring skills	Identify and challenge cognitive distortions in 3+ situations per week using CBT thought record; complete weekly worksheets	12 wks	Active
4	Re-engage in social activities	Attend 1 social event per week; schedule monthly outing with friends; reduce avoidance behaviors tracked via weekly check-in	10 wks	Pending

Modality & Interventions

Cognitive-Behavioral Therapy (CBT) — primary modality. Supplemented with psychoeducation re: anxiety cycle, progressive muscle relaxation, behavioral activation, and motivational interviewing techniques as appropriate.

Jordan Ellis

Progress Notes & Barriers

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Progress to Date

Client attended 3 of 3 scheduled sessions. Demonstrates good insight and engagement. Beginning to apply breathing techniques during acute anxiety episodes. Sleep has improved from 4 to 5.5 hrs/night average.

Barriers to Treatment

Work schedule variability creates session scheduling challenges. Client reports occasional resistance to completing thought records between sessions. Addressing via motivational techniques.

Medications (if applicable)

Escitalopram 10mg daily, prescribed by Dr. Torres as of Feb 2026. Client reports tolerating well with mild initial nausea, now resolved. Coordinating with prescriber quarterly.

Risk Assessment

No current suicidal ideation, intent, or plan. No homicidal ideation. Client contracted for safety; emergency contacts documented. Low risk at time of assessment.

Homework & Between-Session Activities

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Assigned Activities

Next Session Plan

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Next Session Date

Focus Area

Review Date

Authorization & Signatures

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Dr. Sarah Whitmore, LCSW

Licensed Clinical Social Worker · Clinician Signature

Jordan Ellis

Client Signature — Informed Consent Acknowledged

Supervisor Signature (if applicable)

Date Authorized