Each section below uses bullet points with short, sharp key information only.
Behaviour:
- Client’s observable behaviour, mood, and presentation during session.
- Relevant self-reported experiences and contextual factors.
- Appearance, affect, and demeanour.
- Speech, eye contact, or posture.
- Emotional state or mood as observed and/or reported.
- Situational stressors or triggers discussed.
- Risk-related indicators.
Intervention:
- Clinician’s therapeutic interventions, strategies, or techniques used during session.
- Therapeutic framework used.
- Specific tools or exercises used.
- Clinician’s personal style and rationale.
- Collaboration or problem-solving steps taken during session.
- Adjustments to clinician’s approach based on client’s state or feedback.
Response:
- Client’s level of engagement, insight, and emotional response during session.
- Evidence of progress, change, or resistance.
- Client’s feedback on techniques or discussion topics.
- Observations of affect, motivation, or ambivalence.
Plan:
- Agreed-upon goals or homework tasks.
- Plan for upcoming sessions or interventions.
- Referrals, consultations, or coordination with other providers.
- Risk management issues or details of safety plans.
- Updates to treatment focus or diagnosis.
- Next appointment details and ongoing monitoring plan.
