535 Ocean Avenue, Suite 4, Portland, ME 04103

Phone: (207) 370-5389 | Fax: (207) 510-8054 |-Email: info@catt-associates.com

Treatment Plan

Please check the Treatment Plan Tracker via Google Drive for the correct due dates!

Client Legal Name (First, Middle Initial, and Last):*
Client Preferred Name (If Different Than Client Legal Name):
Do not leave as "Unsure / Not Listed." Thank you.
Clinician Name*
Type of Service*
Outpatient Intake Date: *
Date of First Session with Client
HCT Intake Date:*
Date of Referral - Ask Administrative Team
Outpatient Treatment Plan Start Date: *
29 Days from Intake Date Treatment Plan Starts (Please Use Date as Shown on Treatment Plan Tracker)
HCT Treatment Plan Start Date:*
29 Days from Intake Date Treatment Plan Starts (Please Use Date as Shown on Treatment Plan Tracker)
No More Than 30 Days
No More Than 30 Days
Outpatient Treatment Plan End Date:*
Treatment Plan is for One Year - Ends One Year from Start Date
HCT Treatment Plan End Date:*
Treatment Plan is for One Year - Ends One Year from Start Date
No More Than 365 Days
No More Than 365 Days
Outpatient Next 90 Day Treatment Plan Review Date:*
No More Than 90 Days from Treatment Plan Start Date
HCT Next 90 Day Treatment Plan Review Date:*
No More Than 90 Days from Treatment Plan Start Date
No More Than 90 Days
No More Than 90 Days
(icd.codes is a great online resource for finding diagnosis codes and descriptions)
If None Type "N/A"

Long Term Goal

Outpatient Long Term Goal Target Date: *
Long Term Goal Target Date is One Year From Treatment Plan Start Date
HCT Long Term Goal Target Date: *
Long Term Goal Target Date is Three 90-Day CSR's From Treatment Plan Start Date
SHOULD BE 365 (Check Tracker Sheet)
SHOULD BE 365 (Check Tracker Sheet)

Objectives/Short Term Goals (OBJ/STG)

Short Term Goal (1) Target Date*
Outpatient OBJ/STG (1) | Target Date 90 Days:*
HCT OBJ/STG (1) | Target Date 90 Days:*
Should be 89 Days (Check Tracker Sheet)
Should be 89 Days (Check Tracker Sheet)
Outpatient OBJ/STG (1) | Target Date 180 Days:*
HCT OBJ/STG (1) | Target Date 180 Days:*
Should be 178 Days (Check Tracker Sheet)
Should be 178 Days (Check Tracker Sheet)
Does Client Have a Second Short Term Goal?*
Please select an answer
Short Term Goal (2) Target Date*
Outpatient OBJ/STG (2) | Target Date 90 Days:*
HCT OBJ/STG (2) | Target Date 90 Days:*
Should be 89 Days (Check Tracker Sheet)
Should be 89 Days (Check Tracker Sheet)
Outpatient OBJ/STG (2) | Target Date 180 Days:*
HCT OBJ/STG (2) | Target Date 180 Days:*
Should be 178 Days (Check Tracker Sheet)
Should be 178 Days (Check Tracker Sheet)
Does Client Have a Third Short Term Goal?*
Please select an answer
Short Term Goal (3) Target Date
Outpatient OBJ/STG (3) | Target Date 90 Days:
HCT OBJ/STG (3) | Target Date 90 Days:
Should be 89 Days (Check Tracker Sheet)
Should be 89 Days (Check Tracker Sheet)
Outpatient OBJ/STG (3) | Target Date 180 Days:
HCT OBJ/STG (3) | Target Date 180 Days:
Should be 178 Days (Check Tracker Sheet)
Should be 178 Days (Check Tracker Sheet)
Short Term Goal (4) Target Date *
Outpatient OBJ/STG (4) | Target Date 90 Days:*
HCT OBJ/STG (4) | Target Date 90 Days:*
Should be 89 Days (Check Tracker Sheet)
Should be 89 Days (Check Tracker Sheet)
Outpatient OBJ/STG (4) | Target Date 180 Days:*
HCT OBJ/STG (4) | Target Date 180 Days:*
Should be 178 Days (Check Tracker Sheet)
Should be 178 Days (Check Tracker Sheet)
Short Term Goal (5) Target Date *
Outpatient OBJ/STG (5) | Target Date 90 Days:*
HCT OBJ/STG (5) | Target Date 90 Days:*
Should be 89 Days (Check Tracker Sheet)
Should be 89 Days (Check Tracker Sheet)
Outpatient OBJ/STG (5) | Target Date 180 Days: *
HCT OBJ/STG (5) | Target Date 180 Days:*
Should be 178 Days (Check Tracker Sheet)
Should be 178 Days (Check Tracker Sheet)

Additional Details

Unmet Needs*
Identified Risks of Treatment*
Identified Benefits of Treatment*
Necessary Accommodations*
Discharge Criteria*

Client Signature

Is Client/Guardian present or able to sign treatment plan?*
Is Client At Least 18 and Able to Sign*

Client/Guardian Statement:

I have developed this plan with my Provider. It accurately represents my goals and objectives at this point in time. We have already discussed, to my satisfaction, how my participating in this plan can help me, as well as the possible risk involve in my participating in this plan. I also understand that I can request a copy of this Treatment Plan at any time.

Client Verbal Consent as Signature*
Check this box for verbal consent by Client/Guardian
By signing, I am agreeing to the client statement above. (Use your mouse or finger to draw your signature above).
Date of Client Signature:*
Use your mouse or finger to draw your signature above.
Parent / Guardian Name*
Date of Parent / Guardian Signature:*

Clinician Signature

By signing, I acknowledge that the services provided and hereby referenced are in compliance with all applicable regulations and laws. (Use your mouse or finger to draw your signature above).
By signing, I acknowledge that the services provided and hereby referenced are in compliance with all applicable regulations and laws. (Use your mouse or finger to draw your signature above).
Please ensure the correct credentials are selected prior to submission.
Please ensure the correct credentials are selected prior to submission.
Date of Provider Signature*
Date of Provider Signature

Reviewer Signature

Reviewer Credentials

Date of Reviewer Signature

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