A treatment plan is the cohesive thread that pulls together key information about a given client—from the initial assessment through to the unique goals and steps the client agrees to take. This plan creates a foundation for best practices and clinical focus that the provider will address in each session with progress notes.
Treatment plans help guide care for both the client and provider. On occasion, insurance companies will perform chart reviews to verify the services they cover are appropriate. A treatment plan is a key component of the chart review.
Treatment plan requirements
Generally speaking, treatment plans for each client should be:
- Established within the first two sessions
- Updated at least twice a year, but as frequent as once every 90 days
- Signed by the provider.
- For in-person sessions, signed by the client.
- For telehealth sessions, verbal agreement from the client must be noted.
Treatment plans should always be unique to each client, with information specific to that client’s individual presentation and circumstances.
Information to include in a treatment plan
During the first session, providers will complete an initial assessment of the client. From this evaluation, the provider develops a treatment plan with specific goals for the client. This plan creates a thread from the initial assessment through the progress notes, where providers track how well the client is progressing toward these goals over time.
Specifically, most plans will include:
- Client’s name and date of birth
- Type of therapy (e.g. individual, couple, group, etc.)
- Presenting problem
- Reason for treatment (e.g. anxiety, depression)
- Diagnosis (including DSM-V / ICD-10 codes)
- Steps client will take to achieve goals
- Target date to achieve goals
- Intervention methods (e.g. medication, mindfulness, CBT, routines, etc.)
Using Headway's treatment plan template
When on the Clinical tab for a client, you will see a section entitled "Treatment plan". In this section, you'll have the option to add in treatment plan for the client. Our template offers structure, making it easier to write treatment plans that meet insurers' standards.
To create a treatment plan using one of our templates:
- Select "create plan" in the treatment plans section.
- Select "use Headway template" from the options provided, and click begin.
- From there, you'll be guided through the steps to fill out the treatment plan, which includes defining the presenting problem, establishing goals, and listing interventions.
- If you're missing any fields, we’ll highlight them in the right side panel, as pictured below:
Note: You'll need to return and fill out the highlighted fields before moving on.
- Once all steps (chief diagnosis, goals, and interventions) are completed, you'll see a preview of the treatment plan with the client’s details.
- From there, you'll have the option to save a draft of your work or "Sign and save" your plan.
- To "Sign and save":
- Review the treatment plan and scroll to the bottom of the page.
- Click the confirmation checkbox.
- Click the "Sign and save" button to save the treatment plan.
Important note: Once you click "sign and save" the plan cannot be edited.
- To save your work:
- Click the X in the top right hand corner of the page.
- Your treatment plan will be saved, and you can return when you're ready to complete it.
- To "Sign and save":
How Headway keeps data secure
We’re trusted with individuals’ most sensitive information, and take protection very seriously. We’ve built a secure data infrastructure and platform, maintain SOC 2 and HIPAA compliance, and follow industry best practices regarding cloud infrastructure and encryption. Headway does not sell or upload any data to third party publishers.
You’re not required to add treatment plans to your session details. That said, insurers occasionally conduct due diligence, and if they make a request for documentation, we’ll ask that it’s supplied within three business days.
If you do want to add your documentation on Headway, we make it a bit simpler through use of our template.
Exporting client documentation
Yes, contact us and we can provide a secure export of notes or treatment plans you’ve uploaded or written on Headway.
Treatment plan example
- Our clinical team also developed a sample treatment plan for your reference:
Provider Treatment Plan Example
Content warning: While fictitious, these documents contain example symptoms and risks that may be sensitive or upsetting to some viewers.
Template to copy and paste
Please feel free to use the template below by highlighting, and then copying and pasting the content.
Date of birth:
Type of therapy:
- Reason for treatment:
Treatment history (summary):
Client signature and date:
Provider signature and date: