Therapy Treatment Plan Examples: 10 Ready-to-Use Templates for Common Clinical Presentations

The following examples transform the theoretical principles of treatment planning into concrete, diagnosis-driven templates. Each plan is fully documented, meets payer requirements, and demonstrates the “golden thread” linking assessment, diagnosis, goals, interventions, and progress tracking. Use these as clinical models—not copy-paste shortcuts—and always tailor them to your client’s unique presentation.

Depression (Major Depressive Disorder, F32.1)

Presenting Problem (Client‘s Words)

“I can‘t get motivated to do anything. I sleep all the time but still feel exhausted. I’ve stopped seeing my friends and nothing feels enjoyable anymore.” PHQ‑9 score: 18 (moderately severe).

Long‑Term Goals

• Reduce PHQ‑9 score from 18 to ≤9 (mild) within 12 weeks

• Increase meaningful social interactions from 0 to 3 per week within 10 weeks

Short‑Term Objectives (SMART)

• Identify and challenge three negative thought patterns per week using CBT thought records by week 4

• Establish consistent sleep schedule (11 pm → 7 am) 5 of 7 nights by week 6

• Resume two previously enjoyed activities weekly by week 8

• Initiate text/phone contact with one friend weekly by week 4

• Attend one in‑person social activity weekly by week 8

Clinical Interventions

• Weekly 50‑minute CBT sessions targeting cognitive distortions and behavioral activation

• Sleep hygiene psychoeducation and monitoring

• Coordination with prescriber regarding SSRI medication

Progress Monitoring

• PHQ‑9 every 2 weeks

• Sleep log and activity log weekly

• Social contact tracking

Generalized Anxiety Disorder (GAD, F41.1)

Presenting Problem

Excessive worry occurring most days, muscle tension, sleep disturbance, restlessness. GAD‑7 score: 17 (severe). Worry triggers include health, work performance, and family safety.

Long‑Term Goal
Reduce generalized anxiety symptoms and improve emotional regulation and daily functioning.

Short‑Term Objectives

• Reduce self‑reported anxiety severity from 8/10 to 4/10 within 6 weeks.

• Identify three primary worry triggers within 4 sessions.

• Practice a grounding or relaxation exercise daily for 10 minutes and track anxiety levels for 4 consecutive weeks.

• Reduce GAD‑7 score from 17 to ≤10 within 12 weeks.

Clinical Interventions

• Weekly CBT targeting cognitive distortions and worry cycles.

• Psychoeducation on anxiety physiology and threat perception.

• Relaxation techniques (diaphragmatic breathing, progressive muscle relaxation).

• Mindfulness-based skills for present‑moment awareness.

• Referral for psychiatric evaluation for SSRIs if symptoms remain severe.

Progress Monitoring

• GAD‑7 every 2 weeks

• Daily SUDS ratings and relaxation practice log

PTSD (F43.10)

Presenting Problem

Client with military‑related PTSD reports flashbacks, hypervigilance, nightmares, and avoidance of crowds. PCL‑5 score: 58. Trauma occurred during combat deployment.

Long‑Term Goal
Reduce PTSD symptoms, decrease flashback frequency by 50%, and improve daily functioning within 12 weeks.

Short‑Term Objectives

• Identify and track three common PTSD triggers using a daily log by week 2.

• Practice grounding techniques (5‑4‑3‑2‑1 exercise) three times weekly for 4 weeks.

• Attend weekly trauma‑focused therapy (TF‑CBT or EMDR) for 12 consecutive weeks.

• Decrease PCL‑5 score from 58 to ≤30 within 30 weeks.

• Engage in one previously avoided social activity per week for 4 weeks.

Clinical Interventions

• Weekly trauma‑focused CBT or EMDR sessions.

• Psychoeducation on trauma responses and PTSD maintenance cycle.

• Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) as indicated.

• Safety planning and grounding skill training.

Progress Monitoring

• PCL‑5 every 4 weeks

• Flashback frequency log

• Avoidance behavior tracking

Bipolar I Disorder, Depressed Episode (F31.3)

Presenting Problem

Client reports persistent sadness, fatigue, and anhedonia for 6 weeks. Prior manic episode 8 months ago (7 days of euphoria, grandiosity, decreased need for sleep). Currently adherent to lithium 900 mg daily.

Long‑Term Goal
Achieve mood stability over next 6 months by maintaining medication compliance, engaging in weekly therapy, and developing coping strategies for early mood changes.

Short‑Term Objectives

• Stabilize mood and reduce depressive symptoms within 4 weeks.

• Achieve a 30% reduction in depressive symptoms (PHQ‑9 from 24 to ≤17) within 8 weeks.

• Maintain lithium level between 0.6 and 1.2 mEq/L over 3 months.

• Document daily mood ratings, sleep hours, and medication adherence on mood chart for 8 weeks.

Clinical Interventions

• Mood stabilizer management with psychiatric collaboration.

• Psychoeducation on bipolar disorder, triggers, and early warning signs.

• CBT or Interpersonal and Social Rhythm Therapy (IPSRT).

• Sleep hygiene and circadian rhythm stabilization.  

• Safety planning for suicidal ideation.

Progress Monitoring

• PHQ‑9 every 2 weeks

• Mood chart and sleep log weekly

• Lithium levels monthly

5. Panic Disorder with Agoraphobia (F40.01)

Presenting Problem

Client reports sudden, unexpected panic attacks (palpitations, shortness of breath, fear of dying) 3‑4 times weekly. Avoids driving, crowded stores, and being alone.

Long‑Term Goals

• Reduce panic attack frequency from 3‑4 per week to ≤1 per week within 12 weeks.

• Eliminate agoraphobic avoidance of 3 specific situations within 16 weeks.

Short‑Term Objectives

• Identify three catastrophic cognitions preceding panic attacks within 4 sessions.

• Use 4‑square breathing and coping card to reduce panic attacks from 6 times per week to 2 times per week or less.

• Construct exposure hierarchy with 6 items and complete first 3 items by week 8.

• Demonstrate ability to remain in a feared situation until SUDS rating drops by 50% within 12 weeks.

Clinical Interventions

• Weekly CBT with interoceptive exposure (symptom induction exercises).

• In‑vivo exposure exercises (graduated, therapist‑accompanied then self‑directed).

• Relaxation training and breathing retraining.

• Psychoeducation on panic cycle and maintenance factors.

Progress Monitoring

• Panic attack frequency log

• SUDS ratings during exposure

• Avoidance hierarchy completion tracking

OCD (F42.8) – Contamination Theme

Presenting Problem

Client reports intrusive thoughts about germs and contamination, leading to compulsive hand‑washing 30‑40 times daily and avoidance of public restrooms and door handles. Y‑BOCS score: 28 (severe).

Long‑Term Goal
Reduce OCD symptom severity (Y‑BOCS score from 28 to ≤16) within 16 weeks through ERP therapy.

Short‑Term Objectives

• Construct 10‑item ERP hierarchy with SUDS ratings by week 2.

• Complete ERP exercises for the 5 lowest‑SUDS items within 8 weeks.

• Reduce hand‑washing frequency from 30‑40 times daily to ≤10 times daily by week 12.

• Touch one “contaminated” public surface without washing hands for 30 minutes within 12 weeks.

Clinical Interventions

• Weekly ERP sessions (Exposure and Response Prevention).

• Development of detailed exposure hierarchy.

• SUDS monitoring during and after exposures.

• Psychoeducation on OCD cycle, habituation, and inhibitory learning.

• Family involvement as “co‑therapist” for home practice.

Progress Monitoring

• Y‑BOCS every 6 weeks

• ERP hierarchy completion log

• Hand‑washing frequency self‑monitoring

Binge Eating Disorder (F50.2)

Presenting Problem

Client reports binge‑eating episodes (consuming large amounts of food in 2‑hour periods) 3‑4 times weekly, with marked distress and loss of control. BMI 33. PHQ‑9: 14.

Long‑Term Goal
Reduce binge‑eating episodes from 3‑4 per week to ≤1 per week within 16 weeks.

Short‑Term Objectives

• Complete daily food and emotion log for 4 consecutive weeks to identify triggers.

• Eat three planned meals per day at regular intervals (no skipping) for 6 weeks.

• Reduce binge‑eating episodes by 50% within 8 weeks using CBT‑ED strategies.

• Identify and challenge three dysfunctional thoughts about weight and shape per week for 8 weeks.

Clinical Interventions

• Weekly CBT‑ED (Enhanced Cognitive Behavioral Therapy for Eating Disorders).

• Self‑monitoring of food intake, binges, and emotional antecedents.

• Regular eating pattern establishment (3 meals, 2‑3 snacks).

• Cognitive restructuring for overvaluation of weight/shape.

• Relapse prevention planning and trigger identification.

Progress Monitoring

• Binge frequency log

• Weekly weight check (with primary care)

• Eating Attitudes Test (EAT‑26) every 4 weeks

ADHD (F90.8, Predominantly Inattentive Type)

Presenting Problem

Client reports chronic difficulty sustaining attention at work, frequent missed deadlines, losing personal items (wallet, keys, phone), and feeling “overwhelmed by simple tasks.” ADHD‑RS score: 28 (severe). No prior diagnosis.

Long‑Term Goal
Improve executive functioning and reduce ADHD symptoms (ADHD‑RS score ≤16) within 12 weeks.

Short‑Term Objectives

• Implement digital task management system for all work assignments by week 2.

• Break down large assignments into 3‑5 smaller tasks with specific deadlines, completing 80% by assigned due dates.

• Establish consistent morning and evening routines (written checklist) for 5 of 7 days per week for 4 weeks.

• Reduce missed appointments and deadlines from 4 per month to ≤1 per month by week 10.

Clinical Interventions

• Weekly CBT adapted for ADHD (executive function coaching).

• Psychoeducation on ADHD neurobiology and adult presentation.

• Environmental modifications and organizational system setup.

• Referral for psychiatric evaluation for stimulant medication.

• Support for academic/workplace accommodations.

Progress Monitoring

• ADHD‑RS every 4 weeks

• Task completion tracking

• Missed deadline and appointment log

Borderline Personality Disorder

Presenting Problem

Client reports chronic emotional dysregulation, impulsive self‑harm (cutting, 3 episodes in past 2 months), unstable relationships with family and partner, and fear of abandonment.

Long‑Term Goals

• Reduce self‑harm episodes from 3 in 2 months to 0 over 6 months.

• Improve emotion regulation skills and reduce impulsive behaviors within 6 months.

Short‑Term Objectives

• Use diary card to track urges, behaviors, and emotions daily for 8 weeks.

• Learn and practice TIPP skill (Temperature, Intense exercise, Paced breathing, Paired muscle relaxation) to reduce crisis urges to 4/10 intensity.

• Identify three early warning signs of emotional escalation and use distress tolerance skills within 2 minutes of recognition, 4 times per week.

• Attend weekly DBT skills group (13‑week program).

Clinical Interventions

• Weekly DBT (individual + skills group).

• Diary card review and behavioural chain analysis.

• Skills coaching between sessions.

• Family involvement (optional) for psychoeducation.

• Coordinated care with psychiatrist for mood stabilizer/antidepressant as indicated.

Progress Monitoring

• Self‑harm frequency and urge intensity log

• Diary card weekly review

• DBT skills use tracking

Co‑occurring Cocaine Use Disorder & Bipolar Disorder

Presenting Problem

Client with long‑standing bipolar I disorder and cocaine use disorder (active, 3‑4 times weekly). On lithium 900 mg daily but reports missing doses. Referred by employer after positive drug screen.

Long‑Term Goals

• Achieve abstinence from cocaine (negative urinalysis for 8 consecutive weeks) within 12 weeks.

• Stabilize mood and prevent manic/depressive relapse.

Short‑Term Objectives

• Attend weekly urine drug screens with negative results for 8 consecutive weeks.

• Identify mood symptoms as primary triggers for cocaine use and develop alternative coping responses.

• Maintain therapeutic lithium level (0.6–1.2 mEq/L) for 3 consecutive months.

• Attend Bipolar Support Alliance meetings weekly and substance use recovery group twice weekly.

Clinical Interventions

• Outpatient cognitive‑behavioral therapy (CBT) targeting substance use.

• Medication management and adherence support (coordinated with psychiatrist).

• Family meetings and work support group participation.

• Relapse prevention and early warning sign identification.

• Contingency management for negative drug screens.

Progress Monitoring

• Weekly urine drug screens

• Lithium levels monthly

• Urge log and coping strategy tracking

• Bipolar symptom monitoring (mood chart)

Quick Reference: SMART Goals by Domain

References

1. Behave Health. (2026). Mental Health Treatment Plan Templates & SMART Goals.

2. NIH. (2020). SAMPLE TREATMENT PLAN FOR CASE EXAMPLE GEORGE T. (TIP 42).

3. ICD-10 Data. (2026). *2026 ICD-10-CM Diagnosis Code M79.1: Myalgia*.

4. ICD-10 Data. (2026). *2026 ICD-10-CM Diagnosis Code M79.7: Fibromyalgia*.

5. ICD-10 Data. (2026). *2026 ICD-10-CM Diagnosis Code R52: Pain, unspecified*.

6. ICD-10 Data. (2026). *2026 ICD-10-CM Diagnosis Code G89.2: Chronic pain, not elsewhere classified*.

7. ICD-10 Data. (2026). *2026 ICD-10-CM Diagnosis Code F45.1: Undifferentiated somatoform disorder*.