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Treatment Plan


Client Name, ID#, DOB

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone

Provider Name & NPI#

Name
Title
Home Phone

Other agencies involved and if contacted?


Medications?


Problems/Symptoms?


Long Term Goals & Expected Date of Completion?


Short Term Goals, Date Established, Goal Date, Date Achieved?


Interventions/Actions, with whom, by whom?


Provider & Date?

Name
Title

Copyright 2010 by Deborah Lee Urban LPC. All rights reserved.
Revised: April 28, 2010