Therapy Treatment Plan Template - Espyr
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1TREATMENT PLAN
(This form is optional. You may use your own treatment plan form.)
Please type or print legibly.
Client’s Name
Age
Employer
Clinician’s Name
Date
DIAGNOSES:
ICD 10#
Description
TARGET PROBLEMS/SYMPTOMS:
SEVERITY OF SYMPTOMS:
Mild
Moderate
Severe
1.
2.
3.
:
Functional Impairment
TREATMENT OBJECTIVES:
SPECIFIC INTERVENTIONS:
1.
1.
2.
2.
3.
3.
:
Intervention Plan/Time Frame
Excellent
Good
Fair
Guarded
Poor
Prognosis:
Projected Number of Visits
Projected Discharge Date
Counselor Signature
Date
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Parent category: Medical