Treatment Plan & Therapy Agreement

This document outlines our shared understanding of the therapy ahead — the focus of our work, how sessions will run, and the boundaries that keep our relationship safe and effective. It is meant to be a living agreement; we can revise it together as your goals evolve.

Header

Client name:

Therapist name:

Plan date:

Plan period (e.g. "12 weeks"):

Working Diagnosis / Formulation

Clinical formulation in plain language — what we understand about your experience and what may be contributing to it:

Provisional ICD/DSM diagnosis (if applicable):

Summary of the presenting issue:

Treatment Goals

We will focus on three SMART goals — specific, measurable, attainable, relevant, and time-bound.

Therapeutic Approach

Modalities we plan to draw on:

CBT — Cognitive Behavioral Therapy

DBT — Dialectical Behavior Therapy

ACT — Acceptance and Commitment Therapy

EMDR — Eye Movement Desensitization and Reprocessing

Psychodynamic

Humanistic / person-centered

Family systems

Integrative / mixed approach

Group therapy as adjunct

Why this approach fits — rationale:

Session Logistics

Session frequency:

Weekly

Biweekly

Monthly

As-needed

Session length (minutes):

Modality:

In-person

Video

Phone

Office address:

Preferred contact method:

Fees & Payment

Per-session fee:

Package or block pricing, if offered:

Payment methods accepted:

Insurance handling:

In-network — direct billing

Out-of-network — superbill provided for self-submission

No insurance — private pay

Sliding scale agreed

Sliding-scale rate, if applicable:

Cancellation Policy

Cancellation policy details:

I understand 24-hour notice is required to reschedule without charge

I understand late cancellations may be charged at the full session rate

I understand frequent cancellations may prompt us to pause therapy and discuss the way forward

Confidentiality & Limits

What we share, with whom, and the situations in which the therapist may need to take additional steps to keep you and others safe:

I understand confidentiality, its limits, and the privacy risks of electronic communication (email, text, video)

I agree the therapist may contact my emergency contact if there is imminent risk

I consent to release of records to my physician or psychiatrist named below

Physician / psychiatrist name:

Telehealth Considerations

If video or phone sessions are part of our work, please confirm the following:

I will join from a private space where I can speak openly

I have a backup plan if the connection drops (a phone number we can call)

I understand video sessions are recorded only with my explicit consent

Between-Session Communication

Typical response timeframe to messages:

How to reach support during a crisis (informational — your therapist will discuss local crisis lines and emergency services with you):

Signatures

Client signature:

Therapist signature:

Parent / guardian signature (if client is a minor):

Signing date:

I have read and agree to the terms above

Thank you for the trust this represents. Therapy is a partnership; please bring up anything in this agreement that you want to revise — clarity at the start tends to help the work that follows.