Behavioral Activation Plan (Depression)

Date of Service: [Date of service] (Required before signing)

Patient: [Patient name]

Clinician: [Clinician name, credentials]

Session Type: [individual BA session / group BA]

Duration: [Start–stop times or total minutes] (Required before signing)

Modality: [in-person / telehealth (audio-video) / telehealth (audio-only)] (Required before signing)

Session Focus & Treatment Context

[Today's BA focus and rationale], [Depression diagnosis and severity], [Relevant comorbidities affecting BA planning], [Current functional impact across work, self-care, social connection, and sleep-wake routine]. (2–4 sentences using concise, objective language.)

Safety Screening

Screening status: [Completed / Not completed this session] (Required before signing)

• Method: [C-SSRS / ASQ / clinical inquiry / other]
• Result: [Negative / Positive]
• Risk assessment: [Ideation frequency/intensity], [Intent/plan], [Protective factors], [Overall risk level: low / moderate / high] (Only if positive screen or clinical concern)
• Safety interventions: [Safety plan updates, crisis resources reviewed, means reduction, follow-up plan] (Include only those completed)

(If screening not completed: [Reason] and [Alternative safety steps taken].)

BA Formulation

[Working hypothesis linking reduced activity and avoidance to low mood in one sentence]. [Specific avoidance patterns: e.g., staying in bed, canceling plans, procrastination]. [Common triggers for avoidance]. [1–2 alternative response targets to break the cycle]. (Keep to 5–7 lines. If unchanged from prior session, write "Formulation unchanged—see note dated [date].")

Values & Behavioral Targets

(For each active life domain, capture the patient's values and translate into observable targets. List top 1–3 priority targets for this week.)

• Domain: [Relationships / Health / Work–Learning / Recreation / Self-care]
  • Values (patient's words): [Brief value statement]
  • Behavioral targets:
    • [Target: what action; duration/amount; when/where scheduled; minimum viable completion]
• (Repeat for each active domain. Omit domains not addressed this session.)

Activity Monitoring Review

• Monitoring method: [Paper log / App / Calendar / Recall]
• Adherence: [# completed / # planned activities], [Key reasons for missed items, stated neutrally]
• Activities linked to improved mood: [1–2 activities and observation]
• Activities linked to avoidance or mood decline: [1–2 activities and observation]
• Patient insight about mood–behavior link: [One sentence]

(If first BA session: Describe baseline "typical day" pattern instead. If patient did not monitor, document barriers neutrally.)

Behavioral Activation Plan

Scheduling horizon: [Next 7 days / Next 24–72 hours] (Use shorter horizon for severe symptoms or low activation.)

(Include a balanced mix across mastery/competence, pleasure/connection, and self-care. For each planned activity, document details below.)

• Mastery/Competence Activities
  • Activity: [Description], Value link: [Domain], When: [Date/time, duration], Difficulty/confidence: [0–10], Minimum viable version: [Scaled-down step], Supports needed: [People, items, reminders], Priority: [must-do / optional]
  • (Add additional mastery items as needed.)
• Pleasure/Connection Activities
  • Activity: [Description], Value link: [Domain], When: [Date/time, duration], Difficulty/confidence: [0–10], Minimum viable version: [Scaled-down step], Supports needed: [People, items, reminders], Priority: [must-do / optional]
  • (Add additional pleasure/connection items as needed.)
• Self-Care Activities
  • Activity: [Description], Value link: [Domain], When: [Date/time, duration], Difficulty/confidence: [0–10], Minimum viable version: [Scaled-down step], Supports needed: [People, items, reminders], Priority: [must-do / optional]
  • (Add additional self-care items as needed.)
• Graded Task Ladder (Only if addressing avoidance-heavy target)
  • Target behavior: [Behavior]
  • Entry step this week: [Smallest actionable step]
  • Criteria to advance: [e.g., complete on 3 of 4 days or confidence ≥7/10]

Barriers & Response Plans

• If [Barrier: low energy / oversleeping / rumination / perfectionism / scheduling conflict], then [Specific response plan or backup version].
• Environmental supports: [Cues/alarms, prep steps, accountability partner, location setup].
• Self-compassion statement: [Agreed phrase to normalize setbacks and encourage re-engagement].

Homework

• [Daily activity monitoring with mood ratings] — Due: [Date]
• [Complete scheduled BA activities; record completion and confidence] — Due: [Date]
• [Practice response plans when barriers occur] — Due: [Date]
• [Other agreed practice] — Due: [Date] (Only if applicable)

(If no homework assigned: [Reason].)

Outcome Measures

• Depression score: [PHQ-9 / BDI-II / other] = [Score] on [Date]
• Activity completion rate: [# completed / # planned] = [Percentage]
• Trajectory: [Improving / Stable / Worsening] — [Brief implication for plan]

Patient Response

[Patient's understanding of BA rationale], [Observable engagement level], [Preferences expressed in shared decision-making], [Any declined recommendations and alternatives offered]. (Use objective, behaviorally anchored descriptions.)

Coordination of Care

[Party contacted], [Method], [Date], [Purpose and summary]. (Omit this section entirely if no coordination occurred this session.)

Plan for Next Session

• Next appointment: [Date/time or scheduling status]
• Agenda: [Review monitoring, revise schedule, address barriers, advance graded steps]
• Contingency: [Instructions for earlier follow-up if symptoms worsen]

Clinician Signature: [Signature] (Required before signing)

Date Signed: [Date] (Required before signing)