Free Initial Treatment Plan

I. Client Information

• Name: Elowen Hart

• Contact Information: elowen.hart@example.com | (555) 673-8492

• Address: 789 Serenity Grove, Apt. 7C, Meadowvale, State, ZIP

• Emergency Contact: Callum Hart (Brother) | (555) 872-9384

Relevant Background Information:

• Elowen is a 28-year-old graphic designer reporting chronic anxiety symptoms, including difficulty concentrating at work and disrupted sleep patterns for the past year.

• She has no prior mental health treatment history and is motivated to engage in therapy.

II. Diagnosis

1. Primary Diagnosis: Generalized Anxiety Disorder (F41.1)

2. Secondary Symptoms:

   • Persistent worry lasting more than six months.

   • Restlessness, muscle tension, and irritability.

   • Difficulty initiating and maintaining sleep.

3. Diagnostic Tools Used:

   • Clinical interview (using DSM-5 criteria).

   • Generalized Anxiety Disorder 7-item (GAD-7) scale, with a score of 16 indicating moderate to severe anxiety.

III. Treatment Goals

1. Reduce the frequency and intensity of anxiety episodes.

   • Aim for a 50% decrease in self-reported anxiety severity within six months.

   • Minimize physical symptoms (e.g., muscle tension, restlessness) using relaxation techniques.

2. Improve coping mechanisms for anxiety triggers.

   • Equip the client with at least three evidence-based coping strategies for managing workplace stress and social interactions.

3. Enhance overall daily functioning and quality of life.

   • Increase client-reported satisfaction with daily activities and social interactions by 30% within six months.

   • Establish a consistent sleep routine to improve sleep quality by 25%.

IV. Objectives and Interventions

Additional Resources Provided:

• “Managing Anxiety” workbook tailored to Elowen’s needs.

• Access to a local anxiety support group for peer connection.

V. Progress Evaluation

A. Evaluation Plan:
Progress will be evaluated through the following methods:

1. Self-Report Scales:

   • GAD-7 is administered monthly to track symptom changes.

2. Therapist Observation:

   • Regular reviews of anxiety diaries and therapy session insights.

3. Goal Achievement:

   • Measured by improvements in specific goals such as anxiety reduction, coping strategy use, and sleep quality.

B. Evaluation Schedule:

• Initial progress evaluation at the three-month mark.

• Subsequent evaluations every three months to reassess goals and interventions.

VI. Follow-Up Schedule

VII. Provider Information

• Provider Name: Dr. [Your Name], LPC

• License Number: LPC-12345678

• Contact Information: [Your Email]

• Clinic Address: 123 Wellness Lane, Suite 400, Cityville, State, ZIP

Clinic Hours:

• Monday to Friday: 9:00 AM – 6:00 PM

• Saturday: 9:00 AM – 1:00 PM

Emergency Contact Procedure:

• For urgent mental health concerns, clients are instructed to contact the clinic hotline at (555) 789-1012 or visit the nearest emergency room.

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