Behavioral Health Treatment Plan (Person-Centered)

Plan Type: Initial Person-Centered Treatment Plan

Effective Date: [date]

Next Review Due: [date]

Program/Service Line: [e.g., outpatient therapy, CMHC, IOP, crisis follow-up]

Setting: [in-person / telehealth / home-community]

Client Name: [full name]

Preferred Name/Pronouns: [preferred name and pronouns] (Include only if provided.)

DOB: [date]

MRN/ID: [identifier] (Use "MRN pending" if not yet available; do not leave blank.)

Author: [name, credentials, role]

Plan Version: [number] | Last Updated: [date]

[Legal or administrative status, e.g., guardian, court order, voluntary/involuntary status] (Include only if applicable.)

Planning Participants and Shared Decision-Making

[Brief narrative describing who participated in developing the plan, how they participated, and any accommodations provided] (Include the person served and any others they chose to involve. Specify participation method: in-person, phone, or video. Note interpreter or accessibility supports if used.)

• [Name]: [relationship/role] — [in-person / phone / video]
• [Name]: [relationship/role] — [in-person / phone / video]

Person declined involvement of others at this time. (Include this line only if the person declined involvement of family or supports; otherwise omit.)

[1–2 sentence statement describing how goals and services were collaboratively selected with the person]

How to request plan updates outside scheduled reviews: [contact method and responsible team member]

Clinical Summary

(Provide a concise snapshot linking the plan to assessed needs. Do not duplicate the full diagnostic assessment. Limit to 6–12 bullet points total.)

• [Primary presenting concerns and functional impacts across domains: work/school, relationships, self-care, housing, legal involvement]
• [Working diagnoses with status: confirmed / provisional / rule-out]
• [Level-of-care rationale]
• [Risk status summary] (One line if low risk; reference Crisis Plan section if elevated.)
• [Key contextual factors: trauma-informed considerations, substance use risks, cognitive/developmental factors, cultural/spiritual values]
• [Baseline measures with dates, e.g., PHQ-9: 18 on date] (If not collected, state "Not collected" with brief reason.)

Strengths, Preferences, and Recovery Resources

(Use first-person wording where feasible to reflect the person's voice.)

• Strengths and skills: [what I'm good at, what helps me]
• Supports and resources: [natural supports, peer support, community resources]
• Values and roles: [what matters most to me, meaningful life roles]
• Preferences for care: [modality, pacing, provider characteristics, scheduling]
• Barriers and constraints: [transportation, childcare, work schedule, housing, costs]
• Cultural, linguistic, and accessibility needs: [language, accommodations, preferences]

Prioritized Problem List with Goals and Interventions

(Organize problems by priority: 1) safety/medical risk, 2) severity/functional impairment, 3) person's stated priorities, 4) readiness/feasibility. Repeat the following block for each problem/need.)

Problem [#]: [Plain language title]

Associated Diagnosis: [diagnosis or "not yet determined"]

Evidence/Impact: [brief description of symptoms and functional impairment]

Person's Priority Statement: [quote or paraphrase in the person's words] (Include only if provided.)

Baseline: [metric, score, or frequency with date] (If not yet established, write "Baseline to be collected by [date/visit].")

Target Outcome: [desired metric or state]

Target Date: [date]

Status: [New / Active / On Hold / Resolved]

Long-Term Goal (6–12 months): [person-centered description of desired life change tied to functional outcomes]

Short-Term Objectives:

(List 2–6 measurable objectives. Each must include observable behavior or milestone, metric with baseline and target, timeframe, measurement method, and responsible party.)

1. [Objective: specific behavior, symptom change, or functional milestone]

   • Baseline: [value with date]
   • Target Threshold: [value]
   • Target Date: [date]
   • Measurement Method: [scale / self-report / clinician observation / other]
   • Responsible: [person / clinician / care coordinator / other]

2. [Objective: specific behavior, symptom change, or functional milestone]

   • Baseline: [value with date]
   • Target Threshold: [value]
   • Target Date: [date]
   • Measurement Method: [scale / self-report / clinician observation / other]
   • Responsible: [person / clinician / care coordinator / other]

Planned Interventions:

(Map each intervention to specific objectives. Include modality, frequency, duration, setting, responsible party, and any adaptations.)

• Intervention: [type, e.g., CBT with exposure, DBT skills group, MI, medication management, care coordination, peer support]

  • Modality: [individual / group / family / telehealth]
  • Frequency and Duration: [e.g., weekly 50-minute sessions × 12 weeks]
  • Setting: [clinic / home / community / telehealth]
  • Responsible Party: [name and role]
  • Targets Objectives: [objective numbers]
  • Adaptations: [cultural, linguistic, or accessibility adaptations] (Include only if applicable.)

(Repeat Problem block for each additional prioritized problem/need.)

Risk Status and Crisis Plan

(Document current risk status for: suicide/self-harm, violence, grave disability, overdose/withdrawal when applicable, and abuse/neglect concerns with mandated reporting actions if triggered.)

[Risk status summary] (If risk is low and no formal safety plan is required, a concise statement is sufficient, e.g., "No current safety concerns identified. Person denies suicidal ideation, self-harm urges, or thoughts of harming others.")

(If elevated risk is present or program policy requires a safety plan, include the following:)

• Warning Signs: [person-identified indicators]
• Internal Coping Strategies: [self-help strategies]
• Social Supports to Contact: [names and phone numbers]
• Professional Crisis Resources: [clinic contact, after-hours line, 988, mobile crisis]
• Emergency Steps: [when to go to ED or call 911]
• Means Safety: [lethal means counseling documentation] (Include when indicated.)
• Missed Appointment Plan: [who will outreach and within what timeframe]

(Do not infer "no risk" from lack of disclosure. Document what was assessed and what the person reported.)

Care Coordination

(Include this section when multiple services or providers are involved. Omit entirely if the person is receiving single-provider services with no coordination needs.)

• Internal Team Roles: [roles and responsibilities]
• External Providers: [PCP, specialists, school, probation, housing services, etc.]
• Information-Sharing Plan: [what will be shared, with whom, and how often]
• Release/Consent Status: [obtained / pending / declined] (Specify for each coordination target.)
• Referrals: [destination, reason, urgency, expected follow-up, and how connection will be confirmed]

[Documentation if coordination was declined: declination, risk implications discussed, and plan to revisit] (Include only if applicable.)

Progress Monitoring

• Measurement Tools: [symptom scales, functioning measures, substance use tracking, quality of life measures]
• Baseline Values: [values and dates by tool] (If not collected, document reason and plan.)
• Reassessment Schedule: [e.g., every session, every 2–4 weeks, monthly]
• Thresholds Triggering Plan Modification: [e.g., PHQ-9 increase ≥5 points, new suicidal ideation, relapse]
• Review With Person: [how progress will be shared, e.g., shared review of scores at each session]

Review Schedule

Required Review Interval: [interval per program/payer requirements, e.g., every 30 days for CMHC, every 90 days, every 6 months for CCBHC]

Review Participants: [person served and chosen supports]

Triggers for Immediate Plan Revision:

• Hospitalization or ED visit
• New or escalating safety risk
• Significant symptom worsening or relapse
• Change in diagnosis, medications, or level of care
• Major life crisis (housing loss, legal involvement)
• Person requests goal changes or reports barriers preventing engagement

(All updates must include date, summary of changes, and rationale.)

Discharge and Transition Criteria

• Anticipated Discharge Criteria: [clinical, functional, and person-defined benchmarks]
• Step-Down Plan: [frequency reductions, transition to lower level of care, community supports]
• Relapse Prevention Plan: [skills to use, supports to engage, early warning signs, how to re-access services]
• Medication Continuity: [plan for medication management after discharge] (Include if applicable.)
• Follow-up Appointments: [who is responsible for scheduling, timing]
• Documentation for Transition: [what will accompany the person to the next provider]

(Do not define discharge solely as "noncompliance." If engagement challenges occur, document barriers, outreach attempts, and alternative plans.)

Attestations and Signatures

Person Served:

Signature: ______________________ Date: __________

(Or document verbal endorsement per program policy.)

Clinician:

Signature: ______________________ Date: __________

Printed Name: __________________ Credentials: __________

(If the person declines to sign or declines portions of the plan, document: what was offered, what was declined, reason if provided, and plan to revisit. Do not imply consent without explicit documentation.)