Treatment Plan (Play Therapy)

Plan Type: [Initial / Re-evaluation / Update]

Plan Start Date: [Date] Next Review Date: [Date]

Patient Name: [Full name] DOB: [MM/DD/YYYY] Age: [Age]

Parent/Guardian: [Name(s), relationship, legal status] (If legal guardian status is unclear, state this and include plan to verify.)

Service Setting: [outpatient / school-based / community]

Planned Services: [individual play therapy / family sessions / caregiver-only sessions] (Select all that apply.)

Clinician: [Name, credentials]

Date Created: [MM/DD/YYYY]

Consent & Information Sharing

• Consent Source(s): [Parent/guardian name(s)] [Child assent: obtained / not developmentally indicated / declined] [Date]
• Confidentiality Boundaries: [Summary of what is shared with caregivers vs kept private, including safety exceptions and mandated reporting]
• Active Releases of Information: [Entity, scope, purpose, expiration] (List each active ROI.)
• Consent Documentation: [Location: EHR module / scanned form / external system] [Date obtained] (If stored elsewhere, note location.)

Presenting Concerns

[Brief integrated summary of presenting concerns, primary functional impairments (home/school/peers/behavioral regulation), and time course including onset, precipitating events, and recent changes.]

• Referral Source: [caregiver / school / PCP / court / other] [Name/role if applicable]
• Child Report: [Child's stated concerns in developmentally appropriate terms] (Include only if directly reported by child.)
• Caregiver Report: [Caregiver(s) stated concerns and impact on functioning]
• Collateral Report: [Source: teacher / pediatrician / case manager / other]: [Key points] (Include only if available.)

Diagnosis & Clinical Formulation

• Primary Diagnosis: [DSM/ICD diagnosis name] [Code] [Specifiers]
• Secondary Diagnoses/Contextual Factors: [Other diagnoses, medical conditions, psychosocial stressors] (Include only if relevant.)
• Clinical Formulation: [Concise developmental and relational formulation linking symptoms, stressors, and maintaining factors; include hypothesized mechanisms informing play therapy approach.]
• Strengths & Protective Factors: [Child interests and abilities, supportive relationships, caregiver resources, cultural/spiritual strengths, school/community supports]
• Differential/Rule-Outs: [Active differentials under evaluation] (Include only if clinically active; specify data needed.)
• Risk Summary: [Current risk level: low / moderate / high] [Specific behaviors of concern: self-harm / aggression / elopement / none] [Protective factors] (Reference Safety Plan section if risk is elevated.)
• Diagnostic Status: [Confirmed / Provisional] (If provisional, specify additional data needed and timeline.)

Medical Necessity

• Functional Impairment: [Clear linkage of symptoms/behaviors to impairment across settings]
• Play Therapy Rationale: [Why skilled psychotherapy using play modalities is indicated given developmental factors: communication limits, symbolic play capacity, emotion regulation deficits, attachment needs, trauma symptoms]
• Service Level Justification: [Why lower-intensity or non-specialty services are insufficient]
• Prognosis: [Expected trajectory with treatment; anticipated barriers and mitigating supports]

Baseline Status

• Symptom Severity & Functioning: [Observable baseline by domain, frequency/intensity/duration where feasible]
• Caregiver Goal: [Quoted or paraphrased functional goal in own words]
• Child Goal: [Quoted or paraphrased developmentally appropriate goal in own words]
• Standardized Measures: [Tool name, date, score, interpretation] (If not yet administered, specify planned tool(s) and timeline.)
• Observational Baseline: [Affect tolerance, separation comfort, symbolic play capacity, impulse control, relational engagement] (Include items relevant to case.)

Problem List & Treatment Goals

(Number problems by clinical severity and safety risk. Duplicate the structure below for each problem.)

Problem 1: [Brief Label]

Observable Description: [What happens, where/when, functional impact, baseline frequency/intensity/duration if feasible]

Long-Term Goal: [One-sentence patient-centered functional goal]

Short-Term Objectives:

• [Objective 1] [Metric: frequency / duration / scale / behavior count] [Baseline: X] [Target: Y] [Target Date]
• [Objective 2] [Metric] [Baseline: X] [Target: Y] [Target Date]
• [Objective 3] [Metric] [Baseline: X] [Target: Y] [Target Date] (Include 2–4 SMART objectives total.)

Interventions:

• Play Therapy Model: [Child-Centered Play Therapy / directive CBT-informed play therapy / filial therapy / sand tray therapy / Theraplay-informed / trauma-focused play interventions / integrative] [nondirective / directive / integrative] [Brief rationale linked to formulation]
• Core Techniques: [Reflecting feelings, tracking, therapeutic limit setting, narrative play, graduated exposure via play, coping skills rehearsal, sensory modulation] (Link each to objective.)
• Caregiver Components: [In-session coaching, filial sessions, behavior supports, attachment-building activities, home practice expectations] (Link to objectives.)

Measurement: [How progress will be tracked: scale re-administration, caregiver logs, teacher reports, session observation]

Problem 2: [Brief Label]

(Follow the same structure as Problem 1. Add additional problems as needed.)

Service Plan

• Session Frequency: [weekly / biweekly / other]
• Session Length: [Minutes per session]
• Expected Episode Duration: [Number of weeks or through next review date]
• Caregiver Session Frequency: [e.g., every 4th session caregiver-only / 10 minutes at end of each session / monthly family session]
• Step-Down Criteria: [Observable thresholds for reducing session frequency]

Caregiver Involvement

• Participating Caregiver(s): [Names/roles, availability/constraints] (If caregiver involvement is not indicated, provide rationale.)
• Parent Guidance/Coaching: [Planned topics: responding to play themes, co-regulation, limit setting, routines, reinforcement strategies]
• Home Practice: [Brief, realistic activities with frequency: special playtime schedule, coping skills practice, behavior tracking]
• Communication Plan: [Between-session contact parameters, crisis vs non-crisis routes, response times]
• Coordination with Other Supports: [Parenting programs, behavioral supports, how they integrate with therapy]

Coordination of Care

(Include only contacts with appropriate authorization.)

• Contact: [Entity/provider name] [Role: PCP / psychiatry / school counselor / case management / other]
• Purpose: [Medication coordination / academic support / medical rule-outs / service linkage / safety planning]
• ROI Status: [Active / pending] (If pending, specify plan to obtain.)
• Contact Frequency: [One-time / as needed / monthly / per IEP schedule]
• Information Exchange: [Data requested/shared and how it informs treatment]

Safety Plan

Current Risk Status: [No acute concerns identified / Acute or chronic risk present]

(If no acute concerns, state that risk will be reassessed as indicated. If risk is present, complete the following:)

• Behaviors of Concern: [Self-harm ideation/behaviors, aggression, elopement, other]
• Supervision Plan: [Caregiver supervision expectations, environmental structure, monitoring strategies]
• Means Safety: [Lethal means restriction, medication safety] (If applicable.)
• Crisis Resources Provided: [Local crisis line, mobile crisis, ED, 988 Lifeline]
• Escalation Criteria: [Thresholds triggering urgent reassessment or higher level of care]
• Safety Plan Reviewed With: [Child / caregiver(s)] [Date]

Review Schedule & Discharge Criteria

• Planned Review: [Next review date] [Review interval] [Participants: caregiver(s), child as appropriate]
• Early Review Triggers: [Symptom worsening, safety escalation, major contextual changes, non-response, pattern of nonattendance]
• Discharge Criteria: [Goals met with objective criteria / plateau despite modifications / transfer to different level of care / patient/family choice / disengagement with outreach documented]
• Aftercare Plan: [Maintenance schedule, referrals, relapse prevention guidance, post-discharge crisis plan]