Psychotherapy Treatment Plan (Pediatric Psychology)

Document Type: [Initial Treatment Plan / Updated/Reviewed Treatment Plan]

Plan Effective Date: [Date] | Next Review Due: [Date]

Patient Name: [Full name] | MRN: [Medical record number]

DOB: [Date of birth] | Age: [Age in years and months]

Clinician: [Clinician name, degree(s), credentials]

Setting/Modality: [in-person / telehealth (audio-video) / telehealth (phone) / hybrid]

Participants:

• [Child name and relationship]
• [Caregiver name(s) and relationship(s)]
• [Other participants and role, e.g., interpreter, case manager] (Only include if present)

Consent and Confidentiality

Legal guardian providing consent: [Name and legal relationship] (Note source: [caregiver report / documentation on file / both])

Custody context: [Custody arrangement or N/A] (If pending or unclear, state planned verification steps.)

Consent obtained: [written / verbal] on [date]

Assent from child: [yes / no / not applicable] — [Brief note on developmental appropriateness and child's understanding]

Confidentiality limits discussed: [Summary of limits discussed including safety risks, abuse/neglect reporting, and mandated disclosures] (Document content discussed with both caregiver and child as applicable.)

Active Releases of Information:

• [Entity/contact] — [Scope of information to be shared] — [Status: active / expired / pending] — [Validity dates]

Referral and Presenting Concerns

[Brief summary of referral source and reason for initiating or continuing treatment] (1–2 sentences.)

Primary presenting concerns:

• [Target problem]
• [Target problem]
• [Additional concerns as applicable]

[Changes since last plan, if this is an updated plan] (Only include for updated plans; note new stressors, developmental transitions, or school changes.)

Clinical Summary

Working diagnosis/diagnoses:

• [Diagnosis] — [confirmed / provisional / rule-out]
• [Additional diagnosis] — [confirmed / provisional / rule-out] (Only include if applicable)

(If diagnosis is deferred, state that focus is on target symptoms and functional impairment and note plan for diagnostic clarification.)

Clinical formulation: [Concise summary of maintaining factors, developmental considerations, and family/school context relevant to treatment approach]

Strengths and protective factors:

• [Child strengths]
• [Family strengths]
• [Natural supports/community resources]

Relevant medical/educational context: [Medical conditions, IEP/504 status, accommodations, or attendance concerns affecting treatment] (Only include if directly relevant to treatment; otherwise omit this field.)

Functional Baseline

(Quantify with counts, frequencies, or percentages wherever feasible. If a domain has not yet been assessed, state that explicitly rather than omitting.)

• Home and family functioning: [Routines, compliance, sleep patterns, caregiver strain with quantified baseline metrics]
• School functioning: [Attendance rate, academic performance, behavioral concerns, accommodations with quantified baseline metrics]
• Peer and social functioning: [Friendships, social participation, conflict/bullying, isolation with quantified baseline metrics]
• Emotional and behavioral regulation: [Frequency/duration of episodes, triggers, recovery time with quantified baseline metrics]
• Other domains: [Additional functional areas] (Only include if applicable)

Safety Summary

(Include this section even when no acute risk is present. Risk level statements must be supported by documented assessment findings.)

• Suicide/self-harm risk: [Current ideation/intent/plan, history, access to means, protective factors] — Risk level: [low / moderate / high]
• Violence/homicide risk: [Presence/absence of concerns, context, protective factors] — Risk level: [low / moderate / high / not assessed]
• Abuse/neglect concerns: [present / absent] — [Actions taken or mandated reports filed with dates and agencies, if applicable]
• Safety plan: [exists / deferred] — [Location of plan and who has copies] (If deferred, document rationale and target completion date.)

Problem List, Goals, Objectives, and Interventions

(Order problems by clinical severity and safety priority, then by family priority.)

Problem 1

Problem statement: [Plain-language description linking to diagnosis/target syndrome; observable target symptoms/behaviors; functional impairment; baseline metrics; primary settings affected]

Long-term goal: [Meaningful functional outcome in family/child-centered language]

Measurable objectives:

1. Within [timeframe], [who] will [specific behavior/skill] to [target frequency/level] (baseline: [value]; measure: [data source/instrument]).
   • Intervention(s): [Named therapeutic approach/modality] — [Specific techniques to be used]
   • Caregiver role: [Implementation expectations, coaching, monitoring]
   • Between-session practice: [Type, frequency, tracking method]
   • Responsible party: [clinician / caregiver / child / school]
2. Within [timeframe], [who] will [specific behavior/skill] to [target frequency/level] (baseline: [value]; measure: [data source/instrument]).
   • Intervention(s): [Named therapeutic approach/modality] — [Specific techniques to be used]
   • Caregiver role: [Implementation expectations, coaching, monitoring]
   • Between-session practice: [Type, frequency, tracking method]
   • Responsible party: [clinician / caregiver / child / school]

Problem 2

Problem statement: [Plain-language description linking to diagnosis/target syndrome; observable target symptoms/behaviors; functional impairment; baseline metrics; primary settings affected]

Long-term goal: [Meaningful functional outcome in family/child-centered language]

Measurable objectives:

1. Within [timeframe], [who] will [specific behavior/skill] to [target frequency/level] (baseline: [value]; measure: [data source/instrument]).
   • Intervention(s): [Named therapeutic approach/modality] — [Specific techniques to be used]
   • Caregiver role: [Implementation expectations, coaching, monitoring]
   • Between-session practice: [Type, frequency, tracking method]
   • Responsible party: [clinician / caregiver / child / school]

(Add additional problems as needed.)

Treatment Parameters

• Planned session frequency: [weekly / biweekly / other] | Session length: [minutes]
• Estimated treatment duration: [Number of sessions or weeks] (Provisional estimate)
• Modality mix: [Proportion of individual child / caregiver-only / family sessions]
• Step-up criteria: [Indicators prompting increased intensity or higher level of care]
• Step-down criteria: [Indicators prompting decreased frequency or transition to maintenance]
• Conditions for continuation: [Expected improvement/stabilization and how it will be demonstrated]

Caregiver Involvement Plan

Rationale: [Why caregiver participation is integral to this child's treatment]

Caregiver session plan: [Frequency], [with child / without child], [primary focus areas]

Caregiver objectives:

• [Specific caregiver objective, e.g., implement exposures, maintain consistent limits, practice emotion coaching]
• [Additional caregiver objective]

Communication plan: [How progress will be shared with caregivers, cadence, and boundaries regarding confidential adolescent content if applicable]

Outcome Monitoring Plan

• Measures and informants: [Named symptom/function measures] with informants: [child / caregiver / teacher]
• Measurement cadence: [Baseline and interval schedule, e.g., every 4–6 sessions or monthly]
• Decision thresholds: [Criteria for response / partial response / nonresponse] with corresponding actions: [continue / augment / modify approach / consider referral]
• Alternative monitoring: [Method and rationale] (Only include if not using standardized measures)

Care Coordination

• School collaboration: [Consultation goals, IEP/504 involvement, behavior plan alignment] — ROI on file: [yes / no / pending]
• Medical coordination: [PCP updates, specialty team or medication provider communication] — ROI on file: [yes / no / pending]
• Community supports: [Case management, wraparound, mentoring, other services] — ROI on file: [yes / no / pending] (Only include if applicable)
• Barriers to treatment: [Transportation, scheduling, caregiver work constraints, technology access, or none identified]
• Language/cultural considerations: [Interpreter needs, cultural adaptations, family preferences] (Only include if applicable)
• Neurodevelopmental accommodations: [Sensory, processing, attention supports; session adaptations] (Only include if applicable)

Discharge and Transition Criteria

• Discharge criteria: [Objective thresholds linked to treatment objectives indicating readiness for discharge]
• Tapering strategy: [Plan for reducing frequency and transitioning to maintenance/booster sessions]
• Relapse prevention plan: [Skills consolidated, coping strategies, early warning signs, booster session availability]
• Referrals/hand-offs: [Anticipated ongoing care or services and timing] (Only include if applicable)

Attestation

Clinician signature: [Name, credentials] | Date: [Date]

Supervisor co-signature: [Name, credentials] | Date: [Date] (Only include if trainee completed the plan under supervision)

Plan reviewed with caregiver and child: [yes / no] — [Questions answered and agreement documented]