Creating effective intake forms: A guide for therapists
Summary
Use treatment plan templates to document essential clinical information, including diagnoses, presenting concerns, goals, objectives, interventions, strengths, barriers, and review dates.
Apply the SMART framework to create specific, measurable, achievable, relevant, and time-bound goals that support effective treatment planning and objective progress tracking.
Involve clients in clinical goal development by using structured questions that identify priorities, values, strengths, barriers, and actionable next steps.
Update treatment plans regularly based on symptom changes, treatment progress, review schedules, and insurance documentation requirements.
Monitor outcomes through progress notes, standardized assessments, treatment reviews, and client self-monitoring tools to guide ongoing care and plan revisions.
Treatment plans are among the most scrutinized documents in a clinician's practice—by insurers, by supervisors, and during audits. Yet many therapists write them under time pressure, without a consistent structure.
A good treatment plan template solves that. This guide covers the required elements of a treatment plan template, how to write measurable goals using the SMART framework, clinical goal development with clients, when to update plans, insurance documentation requirements, and how to track progress over time.
What elements are required in treatment plan templates?
A treatment plan template is a roadmap that addresses the client's goals and presenting problem(s). The key information to include in the treatment plan is:
Client information: The treatment plan should include basic identifying information, such as the client’s name and date of birth.
Therapist information: The name and credentials of the clinician.
Dates: The treatment plan date, estimated treatment duration, session frequency, and treatment plan review date.
Presenting problem(s): The client's reason(s) for seeking therapy, symptoms, and other clinical information relating to the diagnosis.
Diagnosis: List the client’s diagnosis, including the relevant ICD-10 or DSM-5 code.
Treatment goals and strategy:
Long-term goal: The overall goal of treatment.
Short-term objectives: Three specific actions to achieve the overall goal.
Interventions: The therapeutic approaches (tools, techniques, and strategies) to achieve objectives. For example, distress tolerance skills, emotional regulation techniques, EMDR, cognitive restructuring, and behavioral activation.
Strengths and resources: The client’s internal and external resources that can help them achieve their treatment goals and support them during treatment.
Barriers: Stressors that may impact the success of treatment.
Signatures: Client and therapist signatures and dates.
How to write measurable goals
The SMART goal format is an effective way to develop clinical goals that provide focus and direction. The acronym stands for:
Specific: Defines goals that specify an outcome (a target activity or behavior).
Measurable: Specifies how you’ll track progress towards the goal (such as frequency, duration, or logs). Learning how to write measurable goals helps ensure progress can be evaluated objectively over time.
Achievable: Considers if the goals are realistic based on the client’s internal and external resources and circumstances.
Relevant: Ensures the goal is aligned with the client’s mental health needs and priorities.
Time-bound: Provides a clear timeframe to achieve the goal.
By ensuring goals follow this format, clinicians can create more focused and effective care plans using standardized treatment plan templates.
How to involve clients in goal setting
Treatment plans are most effective when collaboratively developed by the client and clinician, which promotes shared responsibility in achieving the client’s desired outcomes.
Research shows that involving clients in clinical goal development can increase motivation, lower distress, and improve treatment outcomes. Many treatment plan templates include goal-setting sections designed to facilitate this collaborative process.
However, clients may not be familiar with SMART goals or know how to write measurable goals with actionable steps.
To support and involve clients in clinical goal development, clinicians may ask the following types of goal-oriented prompts:
What do you want to achieve?
What are some areas of your life that you’d like to improve or grow?
What are your core values and how does your goal align with them?
When would you like to accomplish this goal?
Why is that important to you?
How does this goal align with your values and long-term goals?
How will you know you have achieved your goal?
How will you measure your progress?
What resources will you need to achieve your goal?
Which strengths will you need to use to accomplish your goal?
How realistic is that goal based on your current situation and resources?
What steps will you take to achieve your goal?
What are some potential barriers to achieving your goal?
How will you overcome those obstacles?
How will you adapt or adjust your goals to overcome barriers?
Alternatively, you could use goal-planning worksheets with the client to hone in on what they want to get out of therapy and develop clinical goals.
When to update plans
As a general rule, update treatment plans every three to six months. Update plans sooner if there is a significant change in the client’s symptoms, circumstances, or diagnosis.
Most electronic health records (EHRs) include a treatment end date or treatment review date in the treatment plan template, which serves as a helpful reminder for when to update plans.
What about insurance requirements?
Insurance companies' requirements vary regarding how frequently a treatment plan should be updated. Most, however, require the treatment plan to be updated every 30 to 90 days to reflect progress toward each goal, changes to objectives, or interventions. Plans may be updated more frequently if clinically indicated.
Outdated plans can trigger claim denials or payment clawbacks during insurer audits or utilization reviews.
Using structured treatment plan templates can help clinicians maintain consistent documentation, track progress over time, and meet payer requirements more efficiently.
How to track progress
Clinicians can track treatment progress in several ways when using treatment plan templates:
During each session, use a progress note template in your EHR that includes the client’s treatment plan, allowing them to update treatment progress in each session note.
Schedule monthly or quarterly treatment reviews and collaboratively review each goal with the client, noting progress, and modify the goals and objectives as needed.
Use standardized measures each month, like PHQ-9, GAD-7, or PCL-5, to track symptom severity. Clinicians could also set up a monitoring system that automatically sends measures to clients and copies the clinician in the email.
Note the client’s functioning and symptom improvements.
Ask the client to complete a daily journal, noting symptoms, sleep quality, or use a specific tracker, like a bipolar mood chart.
Sources
Bailey R. R. (2017). Goal setting and action planning for health behavior change. American Journal of Lifestyle Medicine.
Bovend'Eerdt, T. J., Botell, R. E., & Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clinical rehabilitation.
Geurtzen, N., Keijsers, G. P. J., Karremans, J. C., Tiemens, B. G., & Hutschemaekers, G. J. M. (2020). Patients' perceived lack of goal clarity in psychological treatments: Scale development and negative correlates. Clinical psychology & psychotherapy.
Lindhiem, O., Bennett, C. B., Orimoto, T. E., & Kolko, D. J. (2016). A meta-analysis of personalized treatment goals in psychotherapy: A preliminary report and call for more studies. Clinical Psychology.
How SimplePractice streamlines running your practice
SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.
If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.
Try SimplePractice free for 30 days. No credit card required.
