Creative Arts Therapy Treatment Plan Review/Update

Patient name: [Patient name]

MRN: [Medical record number]

DOB: [Date of birth]

Pronouns: [Pronouns] (Only include if collected; otherwise omit this line)

Location/Program: [Location or program name]

Level of care: [Level of care]

Review type: [routine periodic review / significant change review / pre-discharge review]

Review period: [Start date] – [End date] (If dates are uncertain, include best-known anchor date and note that review period dates require verification)

Date signed: [Date]

CAT discipline: [art therapy / music therapy / dance/movement therapy / drama therapy / expressive arts / integrated CAT]

Session format: [individual / group / family / co-treat]

Delivery method: [in-person / telehealth]

Clinician: [Clinician name], [Credentials]

Total session time: [Minutes] (Include only if payer or policy requires time-based documentation; otherwise omit this line)

Reason for Review / Interval Summary

[Narrative summary of reason for review and clinical course over the interval] (3–6 sentences. State the trigger for review such as routine interval, clinical change, plateau, attendance concerns, or discharge planning. Summarize symptom, functioning, and engagement trends. Note significant context changes including housing, legal, medical, school/work, or family.)

Current Clinical Status

Subjective

[Patient-reported progress, symptoms, functioning, and perceived helpfulness of creative arts therapy] (Include barriers from the patient's perspective. Use brief direct quotes only when clinically or legally meaningful.)

Objective

• Affect and mood: [Observable affect and mood presentation]
• Engagement and attention: [Participation, focus, task completion]
• Interpersonal functioning: [Cooperation, boundaries, initiative with peers/staff]
• Creative process: [Initiation, persistence, flexibility, frustration tolerance, problem-solving] (Describe neutrally without interpretation)
• Movement/somatic observations: [Physical safety considerations and observed tolerance] (Include only for movement-based modalities)

Measures

[Standardized measure results and comparison to prior scores] (Include instrument name, score, and change from baseline or last administration. If no formal measures are used, briefly describe the measurement approach such as behavioral anchors, frequency counts, observation rubrics, or collateral reports. If measures were expected but not administered, state this and include a plan for the next interval. Omit this subsection if not applicable.)

Risk and Safety

(Include this section when risk is clinically relevant, the patient is in a higher level of care, there have been recent crises, or services are being extended. Omit entirely if not indicated.)

• Suicide/self-harm risk: [Ideation / intent / plan / recent behaviors / protective factors] — Risk level: [acute low / acute moderate / acute high / chronic low / chronic moderate / chronic high]
• Violence/other risk: [Violence risk, access to means, recent incidents] (Include only if applicable)
• Abuse/neglect: [Concerns and mandated reporting status] (Include only if relevant)
• Capacity for participation: [Capacity to participate in and benefit from treatment]
• Safety plan: [Current safety plan elements, monitoring, coordination]

Diagnosis and Formulation Update

Current diagnoses (DSM/ICD): [Diagnoses relevant to treatment planning]

Changes since last review: [Added diagnoses / removed diagnoses / rule-outs / remission status] (If no changes, state: No change in diagnoses or formulation since last review dated [date].)

Updated clinical formulation: [Brief formulation focusing on CAT-relevant mechanisms such as affect regulation, interpersonal safety, self-efficacy, narrative integration, or sensory modulation; note changes in predisposing, precipitating, perpetuating, or protective factors]

Strengths and preferences: [Strengths, interests, cultural considerations, and preferences relevant to creative engagement] (Include when clinically relevant)

Progress Toward Goals

(Organize by problem/goal, not chronologically. Use stable identifiers across reviews to show continuity.)

Goal 1: [Goal statement]

Priority: [high / moderate / low]

Baseline and measurement method: [Baseline description and how progress is measured]

• Objective 1.1: [SMART objective statement]

  Status: [Met / Partially Met / Not Met / Discontinued / Revised / Unable to assess]

  Evidence: [Observable evidence linked to measurement method]

• Objective 1.2: [SMART objective statement]

  Status: [Met / Partially Met / Not Met / Discontinued / Revised / Unable to assess]

  Evidence: [Observable evidence linked to measurement method]

Barriers: [Symptoms, environmental constraints, attendance, motivation, cognitive limitations, trauma triggers, group dynamics, access issues]

Facilitators: [Family support, medication adherence, therapeutic alliance, modality match, other facilitators]

Clinical interpretation: [What progress indicates: readiness to advance, need for stabilization, or need to revise objectives]

Goal 2: [Goal statement]

(Repeat structure for each active goal. If progress cannot be determined due to missed visits or incomplete data, document "Unable to assess" with the reason and specify how data will be obtained next interval.)

Treatment Plan Revisions

(Clearly distinguish continued from revised elements. If problem list is unchanged, state this.)

Goals and Objectives

• [Goal/Objective identifier]: [New / Revised / Continued / Discontinued] — Rationale: [clinical change / objective met / objective unrealistic / safety concerns / plateau]
• [Goal/Objective identifier]: [New / Revised / Continued / Discontinued] — Rationale: [reason]

Interventions

• Modality and techniques: [CAT modality and specific techniques] (Describe therapeutic purpose and skilled technique; link to target mechanisms rather than activity descriptions alone)
• Target mechanisms: [Specific symptoms or functional impairments addressed by creative tasks]
• Frequency: [Sessions per week] x [minutes per session]
• Homework/practice: [Assigned practices between sessions] (Include only if applicable)
• Team coordination: [Planned coordination with other providers] (Include only if applicable)
• Creative products: [stored / returned / photographed / destroyed per policy] (Document consent if images are retained)

Frequency, Duration, and Level of Care

Current service parameters: [Current frequency, format, and level of care]

Proposed parameters: [Proposed frequency, format, level of care, and expected next review date]

Medical necessity statement: [Specific symptoms or functional deficits being treated; why skilled CAT intervention is required rather than self-management or recreational activity; rationale for proposed frequency tied to acuity, engagement, and treatment response]

Discharge/step-down plan: [If stepping down or discharging: discharge criteria, aftercare referrals, community resources, handoff plan, and follow-up interval. If continuing: triggers that would prompt discharge consideration at next review.]

Coordination and Communication

(Include only if coordination occurred during this interval or is needed; otherwise omit this section.)

• Team members consulted: [Names, roles, dates]
• Key recommendations: [Summary of recommendations and agreements]
• Collateral obtained: [Source and consent status]
• Interdisciplinary alignment: [How CAT goals integrate with overall treatment plan]

Patient Participation

[Evidence of patient participation in this review and agreement or disagreement with plan changes] (For minors, include guardian participation. If patient declined a recommended change, document risks/benefits discussed and negotiated plan.)

Plan Summary

• [What continues]
• [What changes]
• [What will be measured]
• [Next review date or triggers for earlier review]

Signature

[Clinician signature], [Credentials] — [Date]