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.
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:
We will focus on three SMART goals — specific, measurable, attainable, relevant, and time-bound.
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
Humanistic / person-centered
Integrative / mixed approach
Why this approach fits — rationale:
Session length (minutes):
Preferred contact method:
Package or block pricing, if offered:
Payment methods accepted:
In-network — direct billing
Out-of-network — superbill provided for self-submission
No insurance — private pay
Sliding-scale rate, if applicable:
Cancellation policy details:
I understand that late cancellations may be charged at the full session rate
What we share, with whom, and the situations in which the therapist may need to take additional steps to keep you and others safe:
Physician / psychiatrist name:
Telehealth Considerations
If video or phone sessions are part of our work, please confirm the following:
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):
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Parent / guardian signature (if client is a minor):
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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.