Treatment Plan (Psychotherapy—Older Adult)

Patient: [Name], [DOB], [MRN]

Plan Start Date: [Date]

Plan Review Due Date: [Date]

Last Updated: [Date]

Clinician: [Name, credentials, NPI]

Setting: [outpatient / home-based / assisted living or SNF / telehealth]

Authorization: [Visits authorized and date range] (Include only if applicable.)

Patient Participation: [Yes / No / Partial] — [Brief note on participation in plan development]

Consent Status: [confirmed / pending]

Active ROIs: [List parties with current releases for coordination] (Omit if none.)

Reason for Treatment

(Provide 1–3 brief, patient-centered bullet points of primary presenting concerns, including referral source if applicable. Include older adult context as relevant such as bereavement, care transitions, new medical diagnoses, caregiver stress, chronic pain, loneliness, or cognitive changes. A brief clarifying patient quote may be included. For mid-episode updates with no change, document: "No change in primary presenting concerns since plan dated [date].")

• [Primary presenting concern]
• [Secondary concern] (Include only if applicable.)
• [Referral source or context] (Include only if applicable.)

Diagnoses and Clinical Formulation

Diagnoses:

• [Primary diagnosis: ICD-10 code] [Provisional / Confirmed]
• [Secondary diagnoses: ICD-10 codes] (Include relevant SUD, cognitive disorders, insomnia, grief-related, or trauma-related diagnoses; mark Provisional if pending.)
• [Relevant medical conditions affecting psychotherapy] (Include only if applicable.)

Clinical Formulation: [3–6 sentence narrative linking precipitating factors, perpetuating factors, protective factors/strengths, functional impact, and why psychotherapy—and the selected modality—is expected to help] (Include at plan initiation and when formulation materially changes; otherwise document: "Formulation unchanged; goals updated based on progress.")

Baseline Status and Measures

Symptoms: (Indicate severity with validated scale scores when available or clinician-rated severity with brief observations. Include measurement dates. If baseline metrics are missing, use "Baseline [measure] pending" and add an objective to obtain by next visit.)

• [Measure name]: [score] ([date]) — [Severity or brief observations]
• [Additional measure or clinician-rated severity] ([date]) — [Brief observations]

Functional Status:

• [ADLs/IADLs: independent / needs assistance] — [Where symptoms interfere]
• [Sleep patterns]
• [Social engagement or isolation]
• [Role functioning: family roles, volunteering, caregiving]
• [Medical adherence behaviors] (Include only if targeted in treatment.)

Cognitive/Communication Considerations: [Cognitive screening result (test/date/score) if performed; sensory or mobility limitations; aphasia; health literacy considerations; accommodations needed such as larger print, slower pacing, repetition, written summaries, caregiver support] (Omit if not applicable.)

Safety Summary: [Risk level: none / low / moderate / high] — [Brief rationale] — [Protective factors]

• [Older adult-specific risks: self-neglect / falls risk / medication mismanagement / exploitation or abuse concerns] (Include when relevant.)
• (If risk assessment not performed: "Not assessed—[reason]. Plan to assess by [date].")

Patient Strengths, Preferences, and Context

• Strengths and protective factors: [Coping skills, supports, spirituality, resilience history]
• Treatment preferences: [Modality, session format, caregiver involvement]
• Barriers to care: [Transportation, cost, digital access, cultural/language considerations] (Update when new barriers or supports emerge.)

Planned Psychotherapy Services

Modality: [CBT / IPT / Problem-Solving Therapy / ACT / supportive therapy / reminiscence or life review / trauma-focused therapy / other] — [Brief rationale aligned with formulation; note older adult adaptations such as pacing, cognitive accommodations, caregiver involvement]

Frequency and Duration: [weekly / biweekly / other], [minutes per session], [anticipated episode length], [criteria for adjusting frequency]

Format: Individual psychotherapy. [Caregiver/family involvement: frequency of collateral sessions, purpose, confidentiality limits, ROI/consent status] (Include only if planned.)

Telehealth Plan: [audio-video / audio-only]; [technology assistance plan]; [backup plan if connection fails]; [plan for ensuring private setting] (Omit this subsection entirely if telehealth is not used.)

Target Problems, Goals, and Interventions

(Organize problems by priority: safety first, then severity/acuity, then functional impact.)

Problem #1: [Problem name]

Linked Diagnosis: [Diagnosis]

Severity: [mild / moderate / severe]

Functional Impact: [One sentence describing how symptoms affect daily functioning]

Evidence: [Brief supporting symptoms or measurements]

Long-Term Goal: [Desired meaningful outcome with outcome metric, target value, and timeframe]

Short-Term Objectives: (List 2–4 incremental, measurable objectives with action, measurement method, timeframe, and frequency.)

• [Objective 1]
• [Objective 2]
• [Objective 3] (Include as needed.)

Planned Interventions: (Therapist actions linked to objectives; include psychoeducation, skills training, homework plan with adherence supports; specify dose when helpful.)

• [Intervention 1]
• [Intervention 2]
• [Intervention 3] (Include as needed.)

Patient Responsibilities: [Homework expectations; caregiver role if applicable; identified barriers and mitigation steps]

Problem #2: [Problem name]

(Repeat structure above for each additional problem. If a problem is identified but deferred, document: "Problem acknowledged; not targeted this episode—[reason]. Will revisit [timeframe].")

Risk Management and Crisis Plan

(Include this section when significant risk factors are present: suicidal ideation/history, self-neglect risk, abuse/exploitation concerns, severe substance misuse, recent psychiatric hospitalization, command hallucinations, or significant cognitive impairment affecting safety. If no significant risk factors, document: "No acute safety concerns identified at time of plan.")

• Warning signs: [Patient-specific early signs]
• Internal coping strategies: [List]
• Social supports to contact: [Names/relationships and contact permissions]
• Professional resources: [Clinic contact, crisis line, emergency services]
• Means/environment safety steps: [Details as relevant]
• Elder-specific contingencies: [Welfare checks; caregiver notification plan per ROI and legal/ethical thresholds]

Coordination and Communication Plan

(List other treating professionals involved and specify information to be shared and ROI status. Document medication-related coordination and recommendations for medical evaluation framed as recommendations. Omit this section if no coordination needs exist.)

• [Provider/role]: [Information to share]; [ROI status]
• [Facility staff or case manager]: [Coordination plan] (Include if applicable.)
• [Medication review or medical evaluation recommendations] (Include if applicable.)

Prognosis and Discharge Planning

Prognosis: [Good / Fair / Guarded] — [One-sentence rationale]

Expected Outcomes: [Outcomes tied to goals: symptom reduction, improved coping, maintained or improved function]

Discharge/Step-Down Criteria: [Objective criteria: sustained symptom thresholds, functional goals achieved, no acute risk]

Non-Response Plan: [Time-bound triggers for treatment modification and planned next steps: revise formulation, consult/referral, change modality or intensity]

Plan Review Schedule

Review Cadence: Every [30–90] days or per authorization cycle

Required Updates at Review: Progress toward each goal/objective; updated measures; continued medical necessity rationale; changes to frequency or modality; revised problem list. (Each review must document what changed or explicitly state why no changes are needed.)

Authentication

Clinician Signature: [Name, credentials, date]

Patient Signature/Participation: [Date and documentation of agreement] (If patient declines to sign, document refusal, reason if offered, and how participation was otherwise confirmed.)

(Label any corrections or addenda clearly with date and author; do not obscure original content. For clinically important items—diagnoses, risk level, functional status, cognition—do not leave blank; use: "Not assessed—[reason]. Plan to assess by [date].")