A therapy treatment plan is a short clinical document that records the client's presenting problem, your formulation, the goals you and the client agreed on, the interventions you will use, how progress will be measured, and when the plan will be reviewed. In Australia it sits alongside a GP Mental Health Treatment Plan without being the same document.
That last point causes more confusion than anything else in Australian private practice, so it is worth settling before anything else.
Is a GP Mental Health Treatment Plan the same as your treatment plan?
No. They are two different documents, written by two different people, for two different purposes.
A GP Mental Health Treatment Plan (MHTP) is prepared by a GP or prescribed medical practitioner and is what makes a client eligible to claim a Medicare benefit under the Better Access initiative. Under that initiative, an eligible patient can claim up to 10 individual and up to 10 group therapy mental health treatment services per calendar year, running 1 January to 31 December (Department of Health, Disability and Ageing). The GP has to record specific things in the MHTP: discussion of referral and treatment options, treatment goals agreed with the patient plus patient actions, education about the disorder, a crisis and relapse prevention plan, and the referrals, treatment, support services and follow-up they are arranging (Better Access health professionals fact sheet, March 2026).
Two details from that same fact sheet routinely trip practices up. First, the MHTP is not itself the referral: "a MHTP is not considered a referral", and a valid referral has to be in writing, signed and dated, naming the client, their symptoms or diagnosis, current medications and the number of services. Second, services run in courses, with up to 6 services on the initial referral before the client returns to the referring practitioner for review.
Your treatment plan is the clinical one. It is your formulation and your treatment logic, it lives in the client record, and it is what you are actually accountable for as a practitioner. The MHTP tells you what the GP understood and funded. It does not do your planning for you.
What goes in a therapy treatment plan?
Six components cover almost every setting.
- Presenting problem, in the client's words and in clinical terms. Both, because they are often not the same thing.
- Formulation. The short answer to why this problem, in this person, now, and what maintains it. If you want to go deeper on this step, see our guide to writing a case conceptualisation.
- Goals and objectives. Goals are the outcome the client wants. Objectives are the observable steps that show you are getting there.
- Interventions. The specific modality or protocol, not just "CBT". Which components, in what order, over roughly how many sessions.
- Measures and review points. What you will use to know whether it is working, and how often.
- Risk and safety. Current risk, the safety plan, and what triggers escalation.
Add a signature or a note that the plan was discussed and agreed with the client. That single line does a lot of work if the file is ever reviewed.
How do you write a treatment goal that holds up?
Weak goals are abstract and unfalsifiable. Strong goals name a behaviour, a direction and a way of knowing.
Weak: Client will reduce anxiety.
Stronger: Within 12 weeks, client will attend at least three social events per month without leaving early, with GAD-7 reduced from 16 to below 10.
The second version is measurable, so any reviewer can tell whether it was met, and time-bound, so it forces a review.
A workable pattern is one goal, two or three objectives, and one intervention per objective. Three goals is usually the practical ceiling for a course of six sessions. If you write down eight, you are writing a wish list rather than a plan. Clinicians working with NDIS participants face the same discipline with slightly different language, which we cover in how to write NDIS goals.
What does the Psychology Board require?
This is where a lot of published advice is now out of date. The Psychology Board of Australia's own Code of conduct for psychologists came into effect on 1 December 2025, and the Board has confirmed the APS Code of Ethics is no longer the code it regulates against. If your practice policies still cite the APS Code as the regulatory instrument, they need updating.
Three sections of the new code bear directly on treatment planning.
Section 1.1 asks psychologists to "select assessments and interventions based on evidence, formulation, the purpose of the service", and treats decisions about services as shared decisions made with the client. A treatment plan is simply the written form of that.
Section 1.2 asks you to "practise in a way that is consistent with the purpose of the service agreed upon". Agreeing a purpose and then not recording it makes that standard impossible to demonstrate.
Section 8.5 sets the record-keeping bar: records must be "accurate, up to date, factual, objective, legible and accessible", must be made "at the time of events or as soon as possible afterwards", and must be "sufficient to facilitate continuity of the service provided". A current treatment plan is the fastest way for a covering clinician to pick up a file safely.
Consent runs alongside all of this. Section 4.2 asks you to inform clients of the period for which their consent will be relied on, and to revisit consent when that period passes or the service changes significantly. A treatment plan review is the natural moment to do that.
How do you measure progress without adding an hour of admin?
Pick one primary measure per goal and administer it on a fixed schedule rather than when you remember. Common choices in Australian practice are the K10, DASS-21, PHQ-9, GAD-7 and the ORS or SRS for session-by-session tracking.
There is reasonable evidence this is worth the effort. A multilevel meta-analysis of 58 studies covering 21,699 patients found progress feedback produced a small but significant effect on symptom reduction (d = 0.15), a slightly larger effect for clients whose progress was not on track (d = 0.17), and a favourable effect on drop-out (OR = 1.19) (de Jong et al., Clinical Psychology Review, 2021). Small effects, but they come from an intervention that costs a few minutes per session.
The practical constraint is administration and scoring time. Sending measures ahead of the appointment and having them scored before the client sits down is what makes the schedule survive a busy week. PractaLuma is AI-native practice management software for Australian mental-health practices, and standardised assessments are built in so scores land in the client record rather than a separate spreadsheet.
When should the plan be reviewed?
Set the review date when you write the plan, not later. Three triggers should force one regardless of the date:
- The initial course of sessions is ending.
- The measures have not moved, or have moved in the wrong direction, across three or more sessions.
- Risk, diagnosis or the client's circumstances have changed materially.
On the Medicare side, the Department advises that an MHTP or psychiatrist assessment and management plan "should be reviewed at least once per treatment course", and that a patient will typically not need more than two reviews each calendar year. That review is the GP's, but it is informed by what you send them.
What has to go back to the referring GP?
This is a hard requirement, not a courtesy. On completion of the initial course of treatment, the eligible allied health professional must provide a written report to the referring practitioner covering the assessments carried out, the treatment provided, and recommendations on future management of the patient's disorder. A written report must also be provided at the completion of any subsequent course of treatment.
If your treatment plan is current, that report is a fifteen-minute job rather than an hour of reconstruction from session notes. The plan supplies the assessments and goals, your notes supply what happened, and the review supplies the recommendation. Our guide to writing an effective GP referral letter covers the tone and structure that GPs actually find useful, and report writing can draft the first pass from material already in the file. You can see how that fits a practice's workflow and what it costs on our pricing page.
A worked example
Illustrative only, and deliberately short.
Presenting problem: "I can't get through a work meeting without my heart racing." Social anxiety symptoms, present about two years, worsening since a role change six months ago.
Formulation: Longstanding evaluative fears, activated by increased public speaking demands, maintained by avoidance of meetings and post-event rumination.
Goal: Participate in weekly team meetings without avoidance by week 12.
Objectives: (1) Complete a fear and avoidance hierarchy by session 2. (2) Attend two meetings per fortnight from session 4. (3) Reduce post-event rumination to under 15 minutes.
Interventions: CBT for social anxiety, psychoeducation and cognitive restructuring sessions 1 to 3, graded exposure sessions 4 to 8, relapse prevention sessions 9 and 10.
Measures: GAD-7 at sessions 1, 6 and 10. Weekly avoidance count self-recorded.
Risk: No current risk indicators. Reassess if mood deteriorates.
Review: Session 6, and again before the report to the referring GP.
Frequently asked questions
Do I have to write a treatment plan? No Australian regulation names a document called a "treatment plan". What the Psychology Board's code does require is records sufficient to facilitate continuity of service, and interventions selected on evidence and formulation. A treatment plan is the ordinary way to demonstrate both.
Can I just use the GP's Mental Health Treatment Plan? Not as a substitute for your own. The MHTP records the GP's assessment and the care they arranged. It does not contain your formulation, your intervention sequence or your measures, and it is not the referral either.
How long should a treatment plan be? One page. If it runs longer than that, the detail belongs in your formulation notes or your session notes, not in the plan.
How often should it be updated? At the review points you set, at the end of each course of treatment, and whenever risk or presentation changes materially. Update the existing plan and date the change rather than starting a new document, so the history stays visible in the record.
Does a treatment plan need to be signed by the client? There is no signature rule, but recording that the plan was discussed and agreed is good practice, and it supports the shared decision-making and consent expectations in sections 1.1 and 4.2 of the Board's code.
This article is general information for practitioners, not legal or clinical advice. Check current MBS requirements and your own professional obligations before relying on it.