How to Write a Mental Health Treatment Plan
A mental health treatment plan is a document that details a client’s current mental health problems and outlines the goals and strategies that will assist the client in overcoming mental health issues. To obtain the information needed to complete a treatment plan, a mental health worker must interview the client. The information gathered during the interview is used to write the treatment plan.
Part One of Three:
Conducting a Mental Health Assessment Edit
Gather information. A psychological evaluation is a fact-gathering session in which a mental health worker (counselor, therapist, social worker, psychologist or psychiatrist) interviews a client about current psychological problems, past mental health issues, family history and current and past social problems with work, school and relationships. A psychosocial evaluation can also examine past and current substance abuse problems as well as any psychiatric drugs the client has used or is currently on.
- The mental health worker may also consult a client’s medical and mental health records during the evaluation process. Make sure appropriate releases of information (ROI documents) have been signed.
- Make sure you also appropriately explain the limits to confidentiality. Tell the client that what you talk about is confidential, but the exceptions are if the client intends to harm himself, someone else, or is aware of abuse occurring in the community. 
- Be prepared to halt the evaluation if it becomes apparent the client is in crisis. For example, if the client has suicidal or homicidal ideations, you will need to switch gears and follow crisis intervention procedures immediately. 
Follow the sections of the evaluation. Most mental health facilities provide the mental health worker with an evaluation template or form to complete during the interview.  An example of sections for a mental health assessment include (in order):  
- Reason for referral
- Why is the client coming in to treatment?
- How was he referred?
- Current symptoms and behaviors
- Depressed mood, anxiety, change in appetite, sleep disturbance, etc.
- History of the problem
- When did the problem begin?
- What is the intensity/frequency/duration of the problem?
- What, if any, attempts have been made to solve the problem?
- Impairments in life functioning
- Issues with home, school, work, relationships
- Psychological/psychiatric history
- Such as previous treatment, hospitalizations, etc.
- Current risk and safety concerns
- Thoughts of harming self or others.
- If the patient raises these concerns, stop the assessment and follow crisis intervention procedures.
- Current and previous medication, psychiatric or medical
- Include the name of the medication, the dosage level, the length of time the client has been taking the medication and whether he is using it as prescribed.
- Current substance use and substance use history
- Abuse or use of alcohol and other drugs.
- Family background
- Socioeconomic level
- Parent’s occupations
- Parent’s marital status (married/separated/divorced)
- Cultural background
- Emotional/medical history
- Family relationships
- Personal history
- Infancy – developmental milestones, amount of contact with parents, toilet training, early medical history
- Early and middle childhood — adjustment to school, academic achievement, peer relationships, hobbies/activities/interests
- Adolescence — early dating, reaction to puberty, presence of acting out
- Early and middle adulthood — career/occupation, satisfaction with life goals, interpersonal relationships, marriage, economic stability, medical/emotional history, relationship with parents
- Late adulthood —medical history, reaction to declining abilities, economic stability
- Mental status
- Grooming and hygiene, speech, mood, affect, etc.
- Self-concept (like/dislike), happiest/saddest memory, fears, earliest memory, noteworthy/reoccurring dreams
- Summary and clinical impression
- A short summary of the client’s problems and symptoms should be written in narrative form. In this section, the counselor can include observations about how the patient looked and acted during the evaluation.
- Use the information collected to form a (DSM-V or descriptive) diagnosis.
- Therapy, referral to psychiatrist, drug treatment, etc. This should be guided by the diagnosis and clinical impression. An effective treatment plan will lead to discharge.
Note behavioral observations. The counselor will conduct a mini-mental-status exam (MMSE) which involves observing the client’s physical appearance and his or her interactions with the staff and other clients at the facility. The therapist will also make a decision about the client’s mood (sad, angry, indifferent) and affect (the client’s emotional presentation, which can range from expansive, showing a great deal of emotion, to flat, showing no emotion). These observations assist the counselor in making a diagnosis and writing an appropriate treatment plan. Examples of subjects to cover on the mental status exam include: 
- Grooming and hygiene (clean or disheveled)
- Eye contact (avoidant, little, none, or normal)
- Motor activity (calm, restless, rigid, or agitated)
- Speech (soft, loud, pressured, slurred)
- Interactional style (dramatic, sensitive, cooperative, silly)
- Orientation (does the person know the time, date, and situation he is in)
- Intellectual functioning (unimpaired, impaired)
- Memory (unimpaired, impaired)
- Mood (euthymic, irritable, tearful, anxious, depressed)
- Affect (appropriate, labile, blunted, flat)
- Perceptual disturbances (hallucinations)
- Thought process disturbances (concentration, judgment, insight)
- Thought content disturbances (delusions, obsessions, suicidal thoughts)
- Behavioral disturbances (aggression, impulse control, demanding)
Make a diagnosis. The diagnosis is the main problem. Sometimes a client will have multiple diagnoses such as both Major Depressive Disorder and Alcohol Use. All diagnoses must be made before a treatment plan can be completed. 
- A diagnosis is chosen based on the client’s symptoms and how they fit with the criteria outlined in the DSM. The DSM is the diagnostic classification system created by the American Psychiatric Association (APA). Use the most recent version of the Diagnostic and Statistical Manual (DSM-5) to locate the correct diagnosis.
- If you don’t own a DSM-5, borrow one from a supervisor or colleague. Do not rely on online resources for a correct diagnosis.
- Use the main symptoms the client is experiencing in order to come to a diagnosis.
- If you are unsure about the diagnosis or you need expert assistance, speak to your clinical supervisor or consult with an experienced clinician.