Treatment Plan (Dance/Movement Therapy)

Plan Date: [Date]
Evaluation Date: [Date / Linked evaluation note reference]
Clinician: [Name, credentials, BC-DMT or other registration status]
Setting: [outpatient clinic / inpatient / school / community / home]
Service Modality: [individual / group / family]; [in-person / telehealth]
Referring Provider: [Name / Not provided]

(This is an initial treatment plan for Dance/Movement Therapy. Do not include session-by-session content. If a required element is missing, use explicit placeholders such as "Not assessed," "Pending," or "To be obtained" rather than omitting or fabricating.)

Referral & Presenting Concern

[Brief statement of referral reason and clinical question or service requested, with onset/context and precipitating factors if known] (Do not include full history—reference the evaluation note if needed.)

Patient Stated Goal: "[Direct quote]" (Use quotation marks when quoting patient; paraphrase if direct quote unavailable.)

Diagnoses

• [Primary diagnosis driving DMT need]
• [Additional relevant diagnoses]

(If multiple diagnoses exist, identify the primary diagnosis that justifies DMT. Only include diagnoses provided in documentation; do not speculate. If no formal diagnosis is established, replace list with: Presenting problems/impairments addressed: [Concise list anchored to evaluation findings].)

Clinical Summary

[Synthesis of evaluation findings that justify skilled DMT, linking presenting condition to DMT needs]

Movement-relevant findings: [Findings across applicable domains: emotional/affective regulation, arousal patterns, grounding capacity, interoception/body awareness, nonverbal communication and relational attunement, motor coordination/balance, pain-related movement patterns, cognitive factors affecting participation] (Include only domains assessed and relevant.)

Strengths/Resources/Protective Factors: [Patient strengths and supports]

Barriers to Treatment Engagement: [Safety risks, medical instability, severe dissociation, access barriers, cultural/language considerations] (Omit if none identified.)

Safety & Precautions

• Physical precautions: [Fall risk / weight-bearing restrictions / cardiopulmonary limits / seizure precautions / sensory impairments / none identified]
• Psychological safety: [Dissociation/flashback risk / trauma triggers related to body/touch / panic symptoms / self-harm risk / none identified] (Include early warning signs and titration strategies if applicable.)
• Touch & consent parameters: [Whether therapeutic touch is anticipated; boundaries discussed; how consent will be obtained and revisited / No therapeutic touch planned]
• Risk screen status: [Completed / Pending—specify plan and timeframe]

(Never auto-populate risk negatives unless explicitly assessed and documented.)

Problem List

1. Problem 1: [Observable, clinically grounded problem statement]

   Evidence/Source: [Evaluation findings, clinician observation, patient report]

   Functional Impact: [Impact on ADLs, relationships, work/school, mobility, participation]

2. Problem 2: [Problem statement]

   Evidence/Source: [Findings]

   Functional Impact: [Impact]

3. Problem 3: [Problem statement]

   Evidence/Source: [Findings]

   Functional Impact: [Impact]

(Prioritize: safety first, then function, then participation/quality-of-life. Add or remove problems as appropriate.)

Goals

(Create a goal set for each problem. Goals must be measurable, time-bound, and linked to function. If a measure has not yet been administered, state: "Baseline TBD (measure to be administered [date/session]).")

Problem 1

Patient Goal: "[Direct quote if available]"

Long-Term Goal: Within [timeframe], patient will [observable behavior] as evidenced by [measure/criterion] to support [functional outcome].

Baseline: [Current status with metric and date]

Target: [Target status with metric]

• Short-Term Objective 1: [Objective with metric and timeframe]
• Short-Term Objective 2: [Objective with metric and timeframe]

Problem 2

Patient Goal: "[Direct quote if available]"

Long-Term Goal: Within [timeframe], patient will [observable behavior] as evidenced by [measure/criterion] to support [functional outcome].

Baseline: [Current status with metric and date]

Target: [Target status with metric]

• Short-Term Objective 1: [Objective with metric and timeframe]
• Short-Term Objective 2: [Objective with metric and timeframe]

Problem 3

Patient Goal: "[Direct quote if available]"

Long-Term Goal: Within [timeframe], patient will [observable behavior] as evidenced by [measure/criterion] to support [functional outcome].

Baseline: [Current status with metric and date]

Target: [Target status with metric]

• Short-Term Objective 1: [Objective with metric and timeframe]
• Short-Term Objective 2: [Objective with metric and timeframe]

(Add or remove goal sets to match the problem list. Short-term objectives are optional beyond the first.)

Planned Interventions

Therapeutic frame/approach: [trauma-informed / psychodynamic / attachment-informed / sensorimotor-informed / other]

General session structure: [Opening check-in → Warm-up/grounding → Movement exploration → Verbal processing/integration → Closure/regulation practice] (Adapt as needed.)

Cultural adaptations: [Movement meaning, modesty, music, language, space considerations] (Omit if none.)

Interventions by Problem

Problem 1:

• [Intervention] (Maps to: [Goal/Objective])
• [Intervention] (Maps to: [Goal/Objective])
• Planned progression: [How intervention complexity/autonomy will advance]
• Home practice: [Recommendations with frequency and tracking method, if applicable]

Problem 2:

• [Intervention] (Maps to: [Goal/Objective])
• [Intervention] (Maps to: [Goal/Objective])
• Planned progression: [How intervention complexity/autonomy will advance]
• Home practice: [Recommendations, if applicable]

Problem 3:

• [Intervention] (Maps to: [Goal/Objective])
• [Intervention] (Maps to: [Goal/Objective])
• Planned progression: [How intervention complexity/autonomy will advance]
• Home practice: [Recommendations, if applicable]

(Only include interventions within clinician competence and actually planned. Each intervention must map to at least one goal. Add or remove problem sections to match problem list.)

Frequency & Duration

• Frequency: [Sessions per week / pending authorization]
• Session Length: [Minutes]
• Anticipated Duration: [Number of weeks or visits]
• Service Type: [individual / group] (If group: [expected size], [open / closed])
• Review Interval: [e.g., every 30 days / every 10 sessions]

Care Coordination

• [Interdisciplinary team members and communication plan]
• [Referrals initiated or recommended, with status]
• [Release of Information status: obtained / pending / declined—specify contacts]

(If no coordination needs identified, state: "No coordination needs identified at this time.")

Outcome Measures & Monitoring

• Measure: [Name] | Baseline: [Score/status and date, or "To be obtained (date)"] | Reassessment: [Schedule] | Target: [Criterion]
• Measure: [Name] | Baseline: [Score/status and date] | Reassessment: [Schedule] | Target: [Criterion]
• Movement-based observational anchors: [Behavioral definitions with clear criteria and rating method]

Progress expectations: [Indicators of expected progress vs. plateau/regression]
Plan modification triggers: [Criteria that would prompt plan change, intensification, or discharge]

Medical Necessity & Skilled Rationale

[Justification linking diagnosis/presenting condition → movement/psychophysiological impairments → functional limitations → necessity of skilled DMT by a qualified clinician. Explain why this requires skilled care (clinical reasoning, safety monitoring, titration of activation, therapeutic relationship, movement analysis expertise). State prognosis/rehabilitation potential and justify chosen frequency and duration.]

Patient Participation

• Participation in goal-setting: [Participated fully / Participated partially / Declined—describe process]
• Consent for DMT process: [Obtained / Pending / Declined]
• Touch boundaries: [Discussed and documented / Not applicable]
• Group expectations/confidentiality: [Reviewed / Not applicable]
• Elements declined and adaptations: [Description, if any]

Signatures

Clinician Signature: [Signature]
Credentials: [Credentials]
Date: [Date]

Certifying Clinician Signature: [Signature]
Date: [Date]

(Include certifying clinician signature only if required by setting or payer.)