Treatment Plan Template

Herbal Treatment Plan

Use this template to document clear treatment plans for clients.

Client Information

Client Name: _______________________
Date: _______________________
Consultation: ☐ Initial ☐ Follow-up #_____

Presenting Concerns

Primary concern: _______________________

Secondary concerns: _______________________

Duration: _______________________

Assessment Summary

Key observations: _______________________

Contributing factors: _______________________

Contraindications noted: _______________________

Treatment Goals

Short-term (2-4 weeks):

1. _______________________
2. _______________________

Long-term (2-3 months):

1. _______________________
2. _______________________

Herbal Recommendations

Formula 1:

Herb (Latin name) | Amount | Action
_________________ | _______ | _________________
_________________ | _______ | _________________
_________________ | _______ | _________________

Form: ☐ Tincture ☐ Tea ☐ Capsules ☐ Glycerite ☐ Other
Dose: _______________________
Frequency: _______________________
Duration: _______________________

Lifestyle Recommendations

Dietary suggestions:
_______________________

Foods to increase: _______________________

Foods to reduce: _______________________

Other recommendations:
_______________________

Cautions

Possible side effects: _______________________

When to stop and seek help: _______________________

Follow-Up

Next appointment: _______________________

What to report: _______________________

Signatures

Client Signature: _______________________ Date: _______

Practitioner: _______________________ Date: _______