Treatment Plan or Plan of Care (Drama Therapy)

Patient Name/ID: [Patient name and/or medical record ID]

DOB: [Date of birth]

Plan Status: [New / Review / Revision]

Date Created: [Date]

Effective Date: [Date]

Planned Review Date: [Date]

Setting/Modality: [Outpatient individual / School-based group / Telehealth / Other]

Clinician: [Name, credentials]

Referring Clinician: [Name, credentials] (If not applicable, enter "N/A")

Presenting Concerns and Clinical Rationale

[Brief narrative linking symptom pattern to functional impairment, including duration/course, functional domains affected, current severity, and diagnosis or clinical impression] (Write 3–6 sentences grounded in reported or observed data. For diagnosis, use "Diagnosis per referring clinician:" or "Working clinical impression:" if outside scope of practice.)

Medical Necessity Statement

[Statement establishing why skilled drama therapy/psychotherapy is medically necessary, addressing: clinically significant impairment/distress, why skilled intervention is required rather than recreational programming, how frequency/intensity matches acuity, and expected improvement with timeframe] (Write 2–4 sentences using clear, declarative language. This statement must appear explicitly—do not infer.)

Strengths, Preferences, and Risk Summary

Strengths/Protective Factors:

• [Internal strengths: insight, motivation, creativity, coping capacity]
• [External supports: relationships, housing stability, treatment engagement]
• [Drama-therapy-relevant strengths: comfort with improvisation, interest in narrative, performance experience, tolerance for metaphor/distancing]

Patient Preferences and Considerations:

• [Format preference: individual vs. group; openness to family involvement]
• [Comfort with embodied/performance-based work; boundaries around physical contact]
• [Cultural, spiritual, or identity considerations relevant to role-play/storytelling]
• [Accessibility needs or accommodations]

Risk Summary:

• [Current risk status for self-harm / suicide / violence / dissociation]: [Low / Moderate / High] — [Brief qualifiers if applicable]
• [Safety modifications for experiential work: grounding protocols, pacing, opt-out options, co-regulation plan]

(If risk not assessed in this plan, indicate where risk assessment is documented or when it will be completed.)

Outcome Measures and Baseline

(Include this section only if baseline data and a measurement plan are available.)

Standardized Measures:

• [Measure name] — Baseline: [Score, date]; Re-measurement interval: [Interval]

Functional/Qualitative Metrics:

• [Metric description] — Baseline: [Value]; Tracking method: [Method and interval]

Treatment Plan by Problem

(List problems in priority order: safety first, then greatest functional impairment. Include 2–4 active problems per plan.)

Problem [#]: [Brief title]

Problem Statement: [One sentence describing the symptom/issue, relevant context, and functional impact]

Long-Term Goal: [Patient-centered functional outcome with timeframe, e.g., "Within 12 weeks, patient will..."]

Short-Term Objectives:

• Objective [#].[#]: [Target behavior/skill] — Measured by: [Method]; Target: [Threshold/criterion]; Timeframe: [Duration]
  • Drama Therapy Methods: [Role work / Role reversal / Dramatic projection / Storytelling-narrative / Improvisation / Theater games / Enactment / Script work / Witnessing / Metaphor-distancing]
  • Clinical Rationale: [How the method targets the symptom/skill deficit]
  • Safety Adaptations: [Grounding, titration, opt-out signals, proximity limits] (Include if relevant)
  • Between-Session Practice: [Journaling, narrative prompts, role rehearsal] (Include if assigned)
• Objective [#].[#]: [Target behavior/skill] — Measured by: [Method]; Target: [Threshold/criterion]; Timeframe: [Duration]
  • Drama Therapy Methods: [Selected methods]
  • Clinical Rationale: [Brief rationale]
  • Safety Adaptations: [As needed]
  • Between-Session Practice: [As assigned]

Problem [#]: [Brief title]

Problem Statement: [Symptom/issue, context, and functional impact]

Long-Term Goal: [Functional outcome with timeframe]

Short-Term Objectives:

• Objective [#].[#]: [Target behavior/skill] — Measured by: [Method]; Target: [Threshold/criterion]; Timeframe: [Duration]
  • Drama Therapy Methods: [Selected methods]
  • Clinical Rationale: [Brief rationale]
  • Safety Adaptations: [As needed]
  • Between-Session Practice: [As assigned]

Service Parameters

Frequency: [Sessions per week/month]

Session Length: [Minutes per session]

Episode Duration: [Anticipated length or "ongoing with review every (interval)"]

Format: [Individual / Group / Family / Combination]

(If group format: [Group type: open/closed, skills-based/process]; [Expected size]; [Drama-therapy-specific norms for participation, witnessing, and feedback])

Coordination Plan

(Include only if interdisciplinary coordination is planned.)

• [Provider/Role] — Coordination focus: [Medication / Safety / Attendance / Goals] — ROI: [Obtained / Pending / Declined]

Informed Consent and Creative Works

• Comprehensive informed consent on file: [Date] (Note items reviewed or re-emphasized)
• Consent for experiential methods: [Role-play / Embodiment / Improvisation] — Physical contact boundaries: [Specified boundaries]
• Creative works handling: [Plan for scripts, drawings, recordings, narratives — storage location, access, retention]
• Confidentiality limits reviewed: [Yes / No] (For group therapy, note that group confidentiality was discussed and cannot be guaranteed)

Discharge Criteria

(Omit if the episode is open-ended without defined discharge criteria.)

• Goals substantially met as evidenced by: [Measures/functional indicators]
• Plateau with no further progress expected
• Transition to different level of care
• Patient/guardian choice or attendance policy
• Aftercare plan: [Step-down plan if known]

Signature

Clinician Signature/Credentials: [Signature, credentials]

Date/Time: [Date and time]

Patient/Guardian Acknowledgment: [Signature or notation] (If required by setting)