Psychotherapy · Templates

Treatment plan note template

For creating or updating the living treatment plan—problems linked to measurable goals, planned interventions, responsibilities, and review dates that progress notes can reference.

Template content

Copy or download, then paste into Wavo under My Templates.

Treatment Plan Note

Plan Type
- Initial treatment plan or update; date; participants involved in planning (client, guardian, team).

Diagnoses / Focus of Care
- Working diagnoses or problem list guiding treatment (within scope of practice).

Problems / Needs
- Numbered clinical problems or needs addressed in this plan (client language + clinical framing).

Goals & Objectives
For each problem:
- Long-term goal (broader outcome).
- Short-term measurable objectives (behaviorally specific, time-bound when possible).
- Baseline and target indicators (including scores if used).

Interventions & Modalities
- Planned interventions (e.g., CBT, exposure, DBT skills, MI, family sessions) linked to goals.
- Frequency, duration, and estimated episode length.
- Adjunctive services/referrals (psychiatry, groups, case management).

Client Strengths & Responsibilities
- Strengths leveraged in treatment; client/caregiver responsibilities and homework expectations.

Risk / Safety Plan Elements
- Relevant risk concerns and safety-plan components incorporated into care.

Review & Discharge Criteria
- Planned review date; criteria for successful completion, step-down, or higher level of care.
- Client agreement / shared decision-making documented.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Ties problems to measurable goals so progress notes (GIRP/DAP) stay aligned.
  • Makes modality and intervention choices explicit for audits and continuity.
  • Includes review dates and discharge criteria so plans don’t go stale.
  • Works for initial plans and periodic updates after reassessment.
  • 1Initial psychotherapy treatment plans
  • 2Periodic treatment-plan updates
  • 3Goal-linked outpatient therapy programs

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Plan Type
Initial treatment plan; client participated and agreed. Review in 8 weeks.

Diagnoses / Focus
Social anxiety disorder; co-occurring mild depressive symptoms.

Problems
1) Avoidance of work meetings. 2) Anticipatory anxiety impairing sleep before presentations.

Goals & Objectives
Goal 1: Attend and contribute in meetings. Objectives: (a) attend 100% of standups for 4 weeks; (b) make ≥1 verbal contribution per standup within 6 weeks. Baseline: avoided 2/4 last month.
Goal 2: Reduce GAD-7 from 14 to ≤8 in 8 weeks.

Interventions
Weekly individual CBT with graded exposure and cognitive restructuring ×12 weeks. Optional psychiatry referral if sleep/anxiety persist. Homework: exposure logs.

Strengths / Responsibilities
High motivation; supportive manager. Client will complete weekly exposure homework and bring logs.

Review / Discharge
Review at session 8. Consider discharge/booster when objectives met and GAD-7 ≤8 for 2 consecutive measures; step up if avoidance worsens or SI emerges.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.