Problem Definition

Diagnosis Search

DSM-5-TR diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Presenting problem:

Behavioral definitions:

Maintaining factors:

Baseline severity:

Mild

Moderate

Severe

Medical necessity statement:

Planned modality / frequency:

Strengths / Protective Factors

Goal #1

Long-term goal:

Measurable objective:

Target date:

Intervention / Modality:

Responsible clinician:

Patient tasks:

Goal #2

Long-term goal:

Measurable objective:

Target date:

Intervention / Modality:

Responsible clinician:

Patient tasks:

Crisis / Safety Goal

Include crisis/safety goals (when risk is active)

Safety goal:

Safety plan reference:

Common Interventions

CBT / Cognitive restructuring

DBT skills training

Psychoeducation

Motivational interviewing

Supportive therapy

Exposure / Behavioral activation

Family / Couples work

Case management / Coordination

Referral

Discharge Criteria

Discharge when (check applicable):

Symptom remission — score below clinical threshold

Functional improvement — return to baseline ADL

Outcome measure threshold met

Client self-report of goal attainment

Treatment plateau — no further progress expected

Review

Review date:

Outcome measure:

Revision triggers:

Signatures

Patient / Guardian agreement and date:

Clinician attestation and date:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Counseling - DSM Treatment Planner

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