Counselors Template

Treatment Plan for DBT

A professional Counselors template for healthcare professionals.

About this template

Need a clear and concise DBT treatment plan? This template is designed for counselors and therapists to document treatment goals, objectives, and interventions for clients undergoing Dialectical Behaviour Therapy. It helps to outline the client's presenting problems, treatment goals, and specific DBT skills to be taught. This template ensures all crucial elements are captured, from diagnosis to discharge criteria. Using this template with Heidi, your AI scribe, streamlines the note-taking process, allowing you to focus on your clients. Create comprehensive and compliant treatment plans efficiently, saving you time and improving the quality of care.

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Treatment Plans Diagnosis Major Depressive Disorder, Recurrent, Severe, with Psychotic Features Presenting Problem The client presents with symptoms of depressed mood, anhedonia, sleep disturbance, and suicidal ideation. The client reports feeling overwhelmed and hopeless. Treatment Goals "The client wants to learn coping skills to manage their emotions and reduce suicidal thoughts." The client would like to improve their mood and engage in activities they once enjoyed. The client and clinician collaboratively created the following goal: The client will develop and utilise distress tolerance skills to manage crises. Progress will be measured by tracking the frequency and intensity of suicidal ideation, as well as the client's ability to engage in pleasurable activities. The client was offered a copy of the treatment plan. Objectives Objective 1: The client will increase their awareness of emotions and develop skills to manage them effectively. The client will be able to identify and label their emotions with 80% accuracy by the end of the treatment period. The client will demonstrate the use of at least three distress tolerance skills during times of emotional distress. Treatment Strategy/Intervention - DBT Skills Training - Individual and Group - Weekly - Estimated Completion - 5 months Treatment strategy/intervention details: The client will participate in weekly individual DBT sessions and a weekly DBT skills group to learn and practice skills in the areas of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Modality details: Individual therapy and group therapy. Frequency details: Weekly. Estimated completion details: 5 months. Objective 2: The client will reduce suicidal ideation and develop a safety plan. The client will report a decrease in the frequency and intensity of suicidal thoughts, as measured by the Beck Scale for Suicidal Ideation (BSSI). The client will develop and implement a safety plan to use when experiencing suicidal thoughts. Treatment Strategy/Intervention - Individual Therapy - Individual - Weekly - Estimated Completion - 5 months Treatment strategy/intervention details: The client will engage in individual therapy sessions to address suicidal ideation, develop a safety plan, and process underlying issues contributing to their distress. Modality details: Individual therapy. Frequency details: Weekly. Estimated completion details: 5 months. Discharge Criteria/Planning The client will be discharged when they have achieved their treatment goals, demonstrated consistent use of coping skills, and maintained a stable mood for at least three months. Discharge planning will begin two months prior to the anticipated discharge date and will include a review of progress, a discussion of aftercare options, and the development of a relapse prevention plan. Additional Information Strengths: The client demonstrates a strong desire to improve their mental health and is motivated to engage in treatment. Barriers: The client's psychotic symptoms may interfere with their ability to fully participate in treatment. Supports: The client has a supportive family and is involved in a community support group. Crisis Plan: The client has a crisis plan in place, including contact information for their therapist, psychiatrist, and emergency services. Relapse Prevention Plan: The client will develop a relapse prevention plan to identify triggers, warning signs, and coping strategies. Prescribed Frequency of Treatment The client is prescribed weekly individual therapy sessions and weekly DBT skills group sessions.

Treatment Plans Diagnosis [Diagnosis details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Presenting Problem [Presenting problem details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Treatment Goals [Treatment goals paragraph including a quote from the client about their stated goal(s) for treatment. Description of patient's short-term and long-term goals using language such as "The client wants to...", "The client would like to...", "The client reports their goal for treatment is...", "The client and clinician collaboratively created the following goal:...". Include specific goals stated by the patient. Explain how progress will be measured. Statement about client being offered a copy of the treatment plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objectives [Objective 1 paragraph including strength-based statement, concrete form of measurement, and progress measurement, from DBT modality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Treatment Strategy/Intervention - Modality - Frequency - Estimated Completion - 5 months] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Treatment strategy/intervention details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Modality details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Frequency details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Estimated completion details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Objective 2 paragraph including strength-based statement, concrete form of measurement, and progress measurement, from DBT modality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Treatment Strategy/Intervention - Modality - Frequency - Estimated Completion - 5 months] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Treatment strategy/intervention details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Modality details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Frequency details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Estimated completion details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Discharge Criteria/Planning [Discharge criteria/planning details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Additional Information [Other relevant information if needed, such as strengths or barriers to treatment, supports or other collateral contacts involved in treatment, crisis, relapse, or safety plans, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Prescribed Frequency of Treatment [Prescribed frequency of treatment details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)

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