Treatment Plan
Created by
Scott MacDonald
Specialty
Psychotherapist
Last edited
10/20/2026
Uses
0 times
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About this template
A structured template for documenting a patient’s mental health treatment plan, including the diagnosis, goals, medications, therapies, lifestyle guidance, follow-up, education, and referrals. It supports consistent recording of comprehensive care and ongoing treatment planning.
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Treatment Plan
- Major depressive disorder (MDD), recurrent, moderate severity, with comorbid generalised anxiety disorder (GAD).
- Achieve symptomatic remission of depressive and anxious symptoms (target PHQ-9 < 5, GAD-7 < 5); restore baseline occupational functioning; improve sleep architecture.
- escitalopram (Cipralex®) 10 mg PO daily for 1 week, then increase to 20 mg PO daily; trazodone (Desyrel®) 50 mg PO QHS PRN for insomnia.
- Cognitive behavioural therapy (CBT), weekly 50-minute individual sessions focusing on behavioural activation and cognitive restructuring.
- Maintain strict sleep hygiene (fixed wake time at 07:00, no screens 1 h prior to bed); engage in 30 mins of moderate aerobic exercise 3x/week; eliminate caffeine intake after 12:00 and abstain from alcohol.
- RTC in 2 weeks (28/10/2023 at 14:30) to assess medication tolerability, treatment response, and emergent SI; repeat baseline labs (CBC, electrolytes, TSH) and ECG prior to next visit to monitor QTc.
- Counselled on SSRI mechanism of action, expected 4–6 week latency for full therapeutic effect, and potential transient GI side effects; reviewed safety plan and crisis line contact details (988) in the event of worsening mood or emergent suicidality.
- Referred to outpatient Allied Health Psychology program for structured individual CBT.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.