A treatment plan review checks each goal against the client’s scores and decides what to continue, change, or close. It is measurement-based care, written down. Copy the free template, see a depression review where sessions step down and a PTSD review where the approach changes, and check what goes in each part.
Blank treatment plan review template
FreeTREATMENT PLAN REVIEW Client: [Name or ID] Review date: [Date] Review period: [Which review this is, and the weeks or days it covers] Plan under review: [Date of the current plan, and of the last review] Diagnosis: [Current diagnosis, and any change since the plan was written] Sessions this period: [Attended, cancelled, and missed; format and length] Reviewed by: [Clinician name, credentials; supervisor, psychiatrist, or others who took part] Client took part: [In session, by video, or how else the client was involved] MEASURES OVER TIME Measure 1: [Name; baseline score and date; each score since; today's score] Measure 2: [Name; baseline score and date; each score since; today's score] Individual targets: [What the client counts, such as days attended, panic attacks, nightmares, or shifts worked, then and now] Reading the scores: [Response, remission, no reliable change, or worse, set against the targets in the plan] GOAL REVIEW Goal 1: [The goal as the plan states it] Objective and target: [The objective, its measure, and the date it was due] Where it stands: [Today's numbers beside the target] What helped: [Techniques, skills, or changes the client credits] Barriers: [Attendance, symptoms, life events, substance use, or a poor fit of approach] Decision: [Continue, change, achieved, or discontinued, with the reason and any new target] Goal 2: [The goal as the plan states it] Objective and target: [The objective, its measure, and the date it was due] Where it stands: [Today's numbers beside the target] What helped: [Techniques, skills, or changes the client credits] Barriers: [Attendance, symptoms, life events, substance use, or a poor fit of approach] Decision: [Continue, change, achieved, or discontinued, with the reason and any new target] New problems: [Anything that has come up since the plan, with a goal and measurable objective, or none] CHANGES TO CARE Frequency and length: [Before this review and from now on] Approach: [Unchanged, a new technique, or a different evidence-based therapy, and why] Level of care: [Stay, step up, or step down, and the reason] Medication and referrals: [Psychiatry, primary care, group, or other services, with the client's consent] Risk: [Today's screen, and whether the safety plan was reviewed or changed] CLIENT'S VIEW Progress in the client's words: [What the client says has changed] Scores and experience: [Where the client's view and the scores agree or differ] Next priorities: [What the client wants to work on now] Agreement: [The client's view of each decision, and anything they changed] NEXT REVIEW Discharge or step-down criteria: [Unchanged, or revised at this review] Next review: [Date, and the score change that would bring it forward] Client signature: [Signature and date, or how the client agreed] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient therapy practice, 90-day review, in person
First review of the plan dated August 10. 41-year-old man; major depressive disorder, single episode, diagnosis unchanged. Weekly 50-minute CBT with behavioral activation, in person. Attended 11 of 12 sessions; 1 cancelled for a cold. He declined medication at intake, with an agreement to revisit it if the PHQ-9 hadn’t dropped by week 8.
PHQ-9: 19 at baseline, 15 at week 4, 11 at week 8, 8 today. A 58% drop: a response to treatment, but not yet remission, which needs a score below 5. No thoughts of self-harm reported on the PHQ-9 since week 4. GAD-7: 11 at baseline, 6 today. Activity log: planned, valued activities on 1 day a week at baseline; 5 days a week for the last 4 weeks.
Goal 1, “get my energy and interest back”: PHQ-9 below 10 by week 12, met at 8. Helped: morning walks with his dog, Saturday soccer with his son, and challenging “I’m letting everyone down.” Barrier: energy still dips late in the week. Decision: continue, with a new objective of PHQ-9 below 5 on two readings in a row by week 24. Goal 2, “back at work full time”: returned to full hours in week 9 after a graded return, and has kept them for 4 weeks. Decision: achieved; goal closed.
Frequency: weekly to every 2 weeks for the next 3 months. Approach: same CBT, with the focus moving from activation to relapse prevention, starting a written list of his early warning signs. Level of care: outpatient, unchanged. Medication: not needed, as the PHQ-9 had fallen by week 8; he knows he can raise it again. Coordination: with his consent, a summary to his family physician. Risk: no suicidal ideation, asked directly today; no safety plan needed.
“I’m about 70% back. Mornings are fine now; Sunday nights are still hard.” He suggested moving to every 2 weeks before it was raised. Agrees with closing the work goal. Wants to work on Sunday-night dread, and on keeping the walks going when the weather turns.
Discharge criteria unchanged: PHQ-9 below 5 for 2 months and a written relapse-prevention plan, then a booster session at 3 months. Next review in 90 days, or sooner if the PHQ-9 rises by 5 points or more. Client signed the updated plan in session.
Community mental health clinic, 12-week review, by video
12-week review of the plan dated August 17. 35-year-old woman; PTSD after a robbery at the pharmacy where she works, 18 months ago. Weekly 50-minute sessions by video, at her request skills first: grounding, relaxation, and sleep routines. Attended 10 of 12 sessions; missed 2 during a move. Discussed with the clinical supervisor before the review.
PCL-5: 56 at baseline, 55 at week 4, 54 at week 8, 52 today. A 4-point drop, short of the 10 points generally taken as a clinically meaningful change, and still far above the 31 to 33 often used to flag probable PTSD. PHQ-9: 14 at baseline, 13 today. Nightmares: 5 nights a week at baseline and now, by sleep diary. Work: on leave throughout; one visit to the pharmacy after closing, with her manager, in week 10.
Goal 1, “stop reliving it every night”: PCL-5 below 33 and nightmares on 2 or fewer nights a week by week 16; not on track. Helped: grounding shortens flashbacks from about 20 minutes to 5, by her log. Barriers: she steers away from the robbery, sessions often turned to the week’s crisis, and skills work doesn’t target the memory itself. Decision: change, to a trauma-focused therapy. Goal 2, “back at work”: 2 shifts a week by week 12, not met. Decision: change; target moved to week 24, with graded visits to the pharmacy built into the new therapy. Goal 3, daily muscle relaxation: raised her anxiety, and she stopped after 3 weeks. Decision: discontinued; grounding replaces it.
Approach: prolonged exposure with the same clinician, who is trained in it: 8 to 15 weekly 90-minute sessions, in person. Level of care: outpatient for now. Referral: with her consent, to the clinic psychiatrist for a medication assessment for PTSD, low mood, and sleep; she declined this at intake and agreed today. Risk: denies suicidal ideation, asked directly; screened each session. Drinks wine on 3 or 4 nights a week to get to sleep, up from weekends only; AUDIT-C 5. She will log drinks and raise sleep with the psychiatrist.
“Grounding gets me through a bad night, but I’m still back in that store every time I close my eyes.” Worried about going over the robbery in detail. Chose prolonged exposure after we compared it with cognitive processing therapy, because it includes practice going back to the store. Wants sleep first, then work.
Next review after 6 sessions of prolonged exposure, in about 6 weeks, not 90 days. PCL-5 at every session; PHQ-9 every 2 weeks. If the PCL-5 hasn’t fallen by at least 10 points by then, discuss an intensive outpatient program with her and the psychiatrist. Client agreed by video; electronic signature received the same day.
The evidence behind every decision: each measure from baseline to today, read against the target the plan set.
Avoid: Today’s score on its own. One number can’t show a trend; give the baseline and the readings since.
Every goal from the plan, one at a time: the objective, the evidence, and a decision.
Avoid: “Progressing toward goals” for the whole plan. Review each goal separately, and say what happens to it.
What the review changes: how often you meet, what you do, and where care happens.
Avoid: Keeping everything the same when the scores haven’t moved. No change after a fair trial is a reason to change something, or to record why you won’t.
How the client sees their progress and what they want next. It can differ from the scores, and both belong in the review.
Avoid: A review done about the client instead of with them. Show the scores, ask what they make of them, and record the answer.
When the plan comes back for review, what would end or step down care, and a record that the client agreed.
Avoid: A fixed 90-day date when care has just changed. After a new approach, review sooner, so a second stall isn’t missed.
A review that changes only the review date says nothing happened. Each goal needs its numbers and a decision.
If a measure hasn’t moved after 8 to 12 weeks of regular sessions, change something: frequency, approach, a medication assessment, or level of care. Record what you changed, or why you chose not to.
Measures help most when you go over them together. Show the trend, ask what the client makes of it, and record their view beside the numbers.
A PHQ-9 that has dropped while the client still can’t work is not a finished goal. Weigh the scores with daily functioning and what the client tells you.
A goal dropped from the plan without a decision leaves a gap in the record. Mark it achieved or discontinued, and say why.
Vero Scribe writes the treatment plan review in your template from the review session, with the client’s consent, or from your dictation. You review and edit each goal and decision, then copy it into your record or export it to Word or PDF to sign. Vero works in 60+ languages.
A scheduled check of a mental health treatment plan. You compare each goal with the client’s scores and reports, decide whether to continue, change, or close it, and update the plan with the client. Unlike a progress note, which covers one session, it looks across every session since the plan.
Commonly every 30 to 90 days, depending on the level of care and what your organization or funder requires. Review sooner when something important changes: a crisis, a new problem, a goal met, or scores that stop improving.
Giving a validated measure, such as the PHQ-9, GAD-7, or PCL-5, at regular intervals, going over the scores with the client, and using them to guide treatment decisions. The plan review is where those decisions are written down.
What you checked and what you changed. Check attendance, homework, the diagnosis, and anything new, such as substance use or a medical problem. Then change something: frequency, approach, a medication assessment, or level of care, and review again sooner.
Yes. Copy it, or download it as a Word or text file. No account needed.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
A CBT session in its own order: mood check, agenda, homework review, thought or exposure work, new homework, and feedback.
An EMDR session by phase: target, negative and positive cognitions, SUD and VOC, bilateral sets, closure, and reevaluation.
Data, Assessment, Plan: the three-part session note, with the line between facts and judgment made clear.
Goal, Intervention, Response, Plan: a progress note that opens with the treatment plan goal.
The plan this review updates: problems, goals, objectives, and interventions.
Session notes and plan updates drafted from your sessions, for you to review.
For a psychiatry or other referral that comes out of the review.
For the step-down stage, once the main goals are met.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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