Initial intake and mental health screening, treatment plan and therapy agreement, session notes (SOAP), progress reviews, and termination summaries for psychology counseling practices and licensed therapists
Get started with PocperThis 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.
Client name:
Therapist name:
Plan date:
Plan period (e.g. "12 weeks"):
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.
# | Goal | Measurable Indicator | Target Review Week |
1 | |||
2 | |||
3 |
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 frequency:
Weekly
Biweekly
Monthly
As-needed
Session length (minutes):
Modality:
In-person
Video
Phone
Office address:
Preferred contact method:
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 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
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:
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
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):
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.
The Treatment Plan & Therapy Agreement template is a ready-to-use form from Pocper's Psychology Counseling Practice pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.