Ct. will learn and be practicing at least 2 anxiety ...



TREATMENT PLAN (ANXIETY, SAMPLE)DATE:4/3/21DIAGNOSIS NAME AND CODE:F41.1 Generalized Anxiety DisorderMODALITY PLANNED (Individual, Couples, Family, Group) IndividualFREQUENCY/LENGTH OF SESSIONS PLANNED: Once weekly, 45 minutesESTIMATED LENGTH OF TREATMENT:6 monthsTREATMENT GOALS (symptom-focused) and OBJECTIVES (how will you measure goals were achieved?) Include the words “as measured by” in objectives. Should be Specific, Measurable, Relevant to Diagnosis, and Medically-Necessary.LONG-TERM GOAL #1:Reduce overall frequency, intensity and duration of episodes of high anxiety so that functioning is no longer impairedTARGET DATE:10/3/21Short-Term Objective 1: Ct. will learn and be practicing at least 2 anxiety reduction techniques when anxiety spikes (above a 5, on scale of 1-10, with 10 highest), as reported by clientEstimated Completion Date, Objective #1:7/3/21Short-Term Objective 2: Ct will report decrease in daily muscle tension, restlessness, irritability, and difficulty concentrating. Will no longer be scoring in the "Severe Anxiety" levels on GAD-7.Estimated Completion Date, Objective #2:7/3/21LONG-TERM GOAL #2:Reduced avoidance of work meetings and lower level of anxiety when in meetings. Will feel able to speak in meetings.TARGET DATE:7/3/21Short-Term Objective 1:Ct will report reduced anxiety (maximum of 5 out of 10) when attending work meetings, no avoidance of meetings, and be making at least one comment or asking one question in each meetingEstimated Completion Date, Objective #1:7/3/21Short-Term Objective 2:Ct. will be keeping anxiety journal. Will be able to identify 3 types of distorted thinking and irrational beliefs from the past and present that contribute to anxiety, and will report ability to challenge these as they occurEstimated Completion Date, Objective #2:7/3/21INTERVENTIONS PLANNED (make as client-centered as possible)XPeriodically administer questionnaire(s) to assess symptoms, monitor progress, and monitor effectiveness of treatment; name questionnaire(s): Will administer Burns Anxiety Inventory and GAD-7 every 3 months Anger Management Training (describe):XCBT/ Help ct. identify distorted thinking/black and white thinking; Cognitive Restructuring, particularly around fear of meetingsAssertiveness/ Communication Skills Training (describe)XCoordinate care .... with psychiatristTeach conflict-reduction techniques (describe):Couples or Family therapy to help therapist with assessment/diagnosis, to identify relationship dynamics that might be contributing to client symptoms, and help significant other(s) respond more effectively to client symptomsCrisis Intervention / Create safety plan (describe):DBT -- teach distress tolerance skills (describe)Substance Use/Other Addiction Counseling: Help client identify triggers, develop ways to cope with urges; Relapse Prevention (details):EMDR aimed at (be specific):Grief/Trauma-Resolution Treatment (describe):Help ct. identify / overcome obstacles to building/maintaining support systemXAssign reading/writing (describe/name): Anxiety journalHelp client create self-care plan (details):Help ct. identify codependent behavior, and to identify/set desired boundaries (describe)Have client keep journal to increase awareness ofXTeach Mindfulness/Meditation for anxiety reductionMotivational Interviewing focused onPlay Therapy/Art Therapy (describe)Psychodynamic psychotherapy (focused on)Psychoeducation aboutRefer to Group/Other referrals (details):Refer for medical evaluation /medication evaluation (state which, say why):XTeach client relaxation techniques: Breathing exercises, progressive relaxation, visualization, body scans, etc.XSystematic Desensitization/Exposure Therapy (say more) Assign progressive increasing participation at work meetings and use in-vivo desensitization in sessions to help client practice handling anxietyXTake history of symptoms/dysfunctional behavior/relationships. Help ct. identify conflicts from the past that form basis of current symptoms and unhelpful repetitive behaviors. Identify unconscious motivations, and secondary gainsAssist client in strengthening decision-making and problem-solving skills (describe):XTeach coping skills for when ct is. emotionally dysregulated (describe):Teach techniques to improve sleep (describe):XHomework assignments/Other:Give client exercises from the Anxiety WorkbookXOther: Assign client helpful apps, including CalmOTHER INTERVENTIONS/COMMENTS SPECIFIC TO CLIENT (if any): Therapist Signature:Thelma Therapist, LMFTDate Created:4/3/21Client Signature:John JonesDate Reviewed with Client(s):4/11/212nd Client signature, if applicable:TREATMENT PLAN UPDATE (ANXIETY, SAMPLE)DATE: 7/3/21PROGRESS TOWARD GOAL #1: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Ct is reporting episodes of anxiety that are less frequent, shorter, and less severe NEW TARGET DATE:10/3/21Progress To Objective 1: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Client reports attempting progressive relaxation and meditation when anxiety spikes which often helps but still reports periods of high anxiety about twice weekly where she is unable to calm herself with these tools Estimated Completion Date:10/3/21Progress to Objective 2: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By: Client reporting reduced levels of muscle tension, better concentration, less irritability. Usually scoring in Moderate Anxiety level on GAD-7, but at times can score higher -- continue to monitorEstimated Completion Date:10/3/21If Objective(s) Achieved/ Resolved, is there New Objective for Goal #1?New Short-Term Objective Ct will report scoring in the Mild Anxiety level on GAD- 7.Estimated Completion Date:10/3/21PROGRESS TOWARD GOAL #2: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Ct currently reports reduced anxiety related to work meetings. NEW TARGET DATE:10/3/21Progress To Objective 1: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By:Ct reports reduced anxiety (maximum of 5 out of 10) when attending work meetings, is no longer missing meetings. However, continues to feel too anxious to make comments or ask questions in meetingsEstimated Completion Date:10/3/21Progress to Objective 2: AttemptingPartly AchievedAchieved, Needs MaintenanceResolvedWorseningXAs Evidenced By: Ct. reports keeping anxiety journal. Is able to identify distorted thinking that fuels work-related anxiety. However, continues to have difficulty challenging catastrophizing related to making mistakes if speaks in meetings.Estimated Completion Date:10/3/21If Objective(s) Resolved/ Achieved, is there New Objective for Goal #2?New Short-Term Objective Estimated Completion Date:IF NEW GOALS BEING ADDED, ENTER BELOW, with OBJECTIVES. OTHERWISE SKIP SECTIONNEW LONG-TERM GOAL (OPTIONAL):TARGET DATE:Short-Term Objective 1: Estimated Completion Date, Objective #1:Short-Term Objective 2:Estimated Completion Date, Objective #2:TREATMENT PLAN ADJUSTMENTS NEEDED? (choose one):Continue with plan without adjustments, ORXContinue plan with adjustments (name adjustments, ex. new interventions): Increase in-vivo session work, with ct. visualizing work meetings and mistake-makingBring in partner to aid in diagnosis and treatment planning for client, and to see if relationship dynamics may be playing a part in maintaining or exacerbating anxietyTYPE /FREQUENCY/DURATION OF SESSIONS:Individual, weekly, 45 minute; One couples session planned at this timeNEW ESTIMATED DATE OF THERAPY COMPLETION:10/3/21Therapist Signature:Thelma Therapist, LMFTDate Created:7/3/21Client Signature:John JonesDate Reviewed with Client(s):7/11/212nd Client signature, if applicable: ................
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