Treatment Plan Review/Update (Play Therapy, 90-Day)

Client: [Client name and identifier]

Review Period: [Start date] to [End date]

Prior Plan Review Date: [Date]

Date of Service: [Date] (If no face-to-face service occurred, enter "Non-face-to-face treatment plan update")

Location: [clinic / school / home / telehealth]

Participants: [Child, caregiver(s), others present]

Clinician: [Name and credentials]

Session Start/Stop: [Start time] – [Stop time] (Include only if billable encounter)

Interventions This Encounter: [Brief statement of therapeutic interventions used] (Include only if billable encounter)

(This is a treatment-plan-level document. Document play-based observations only as evidence supporting goals, risk, diagnoses, or functional status—not as session process notes or play-by-play narratives.)

Reason for Review and Interval Summary

Review Type: [Routine 90-day review / Triggered by: symptom change, risk event, hospitalization, custody change, payer request, other]

[3–5 sentence synopsis of clinical and functional changes since last review, including overall progress trajectory: improving / stable / worsening / mixed]

Current Diagnoses and Functional Status

• Diagnoses: [Current working diagnoses with ICD/DSM codes] (Note any diagnostic changes this interval with brief rationale.)
• Functional Impairment: [Current functioning across relevant domains: home/family, school/daycare, peer relationships, emotional regulation, behavioral concerns, anxiety/mood/trauma symptoms]
• Strengths and Protective Factors: [Child and family strengths, supports, protective factors]

Treatment Summary This Interval

• Attendance: [Scheduled frequency vs. sessions attended; cancellations; no-shows; patterns or barriers]
• Modalities: [child-centered / directive / play-based CBT / sand tray / filial / trauma-focused / other]
• Caregiver/Family Work: [Caregiver sessions, parent coaching, family sessions, collateral consultations]
• Key Interventions: [3–5 therapeutic mechanisms emphasized this interval, e.g., emotion identification through symbolic play, graduated exposure within play, caregiver coaching for co-regulation] (Describe mechanisms, not activity details.)

Progress Toward Treatment Goals

(Organize by problem area in order of clinical priority. Repeat this block for each problem.)

Problem [#]: [Brief statement linking symptoms to functional impairment]

Long-Term Goal: [Broad outcome in family-friendly language]

Objective (from prior plan): [Measurable target]

Status: [Met / Partially Met / Not Met / Regressed / Discontinued]

• Evidence: [Standardized measure scores with baseline vs. current, caregiver/teacher report frequencies or ratings, clinician observations linked to targeted behavior/skill]
• Barriers: [Factors affecting progress and steps taken to address them]

(Repeat objective–status–evidence–barriers for additional objectives under this problem as applicable.)

Updated Treatment Plan

Plan Effective Date: [Date]

Next Review Due: [Date]

Problem [#]: [Clinical symptoms and functional impact]

Long-Term Goal: [Broad desired outcome]

Short-Term Objectives:

• Within [timeframe], child will [observable behavior/skill] from [baseline] to [target] as measured by [data source].
• (Add additional measurable objectives as needed.)

Interventions:

• Therapist: [Play-based techniques, skills rehearsal, exposure/processing as indicated]
• Caregiver/Home: [Coaching elements, home practice, tracking method]
• School/Collateral: [Coordination with school, behavior plan alignment] (Include if applicable.)

Criteria for Modification: [Improvement thresholds prompting step-down; deterioration thresholds prompting intensification]

Service Parameters

• Frequency/Duration: [e.g., weekly 45-minute child sessions, monthly caregiver check-ins] (Note changes from prior plan with clinical justification.)
• Modality: [in-person / telehealth / hybrid]
• Participant Structure: [child-only / caregiver present / family sessions]

Risk Assessment

• Suicidal Ideation/Self-Harm: [denies / endorses] (If endorses, include intensity, recent behaviors, time frame.)
• Aggression/Violence Risk: [Current status and recent incidents]
• Abuse/Neglect Concerns: [Current concerns and actions taken]
• Elopement Risk: [Current status] (Include if relevant to this child.)
• Safety Plan: [Reviewed/updated; key elements] (If no safety plan indicated, state brief rationale.)
• Level of Care: [Referrals to higher level of care with rationale] (Include if applicable.)

(If risk not formally assessed this interval: "Not assessed due to [reason]; will complete by [date/visit].")

Coordination of Care

• Active Releases: [School, pediatrician, psychiatry, other]
• Collateral Contacts: [Date – Party – Purpose – Outcome] (Add lines as applicable.)
• Referrals: [Referrals made and status]

Medical Necessity Statement

[Narrative addressing: diagnosis and functional impairments being treated; why services remain necessary at current intensity; skilled interventions requiring a trained clinician; progress achieved and why continued treatment is expected to produce further improvement or prevent deterioration. If progress has been limited, explain barriers and how plan changes address them.]

Participation and Consent

• Caregiver/Guardian Review: [Plan reviewed with caregiver; agreement or disagreements and how addressed]
• Child Participation: [Developmentally appropriate involvement in goal setting/review]
• Consent Updates: [New consents obtained, if any]
• Unable to Obtain: [Attempts made and plan to obtain] (Include if applicable.)

Signatures

Clinician Signature: _____________________________ [Name, credentials] Date: ______

Caregiver Acknowledgment: _____________________________ Date: ______ (Include if required by organization.)

(Generation guidance: Omit sections that are not applicable—do not write "N/A." For high-importance items that cannot be completed, use explicit placeholders. Never infer safety/risk status, abuse/neglect concerns, custody/consent status, or attendance patterns. Clinical impressions from observation are acceptable when clearly labeled. Maintain the golden thread: diagnosis → symptoms/impairment → goals → interventions → evidence. Describe play therapy as psychotherapy with clinical targets and functional outcomes.)