Psychotherapy Session Note Template

Session Focus

[What issue / topic was discussed during the session?]

Session Description

[What was reported by the patient? The process of discussion and interaction.]

Chief Complaint

Mental status examination

- Appearance and Behavior: [Tell if well-groomed, casually dressed, cooperative, engaged in session, and good rapport] - Speech: [Tell if speech is normal rate, volume, and tone] - Mood and Affect: [Tell patient’s reported mood; tell if patient's affect congruent with mood] - Thought Process: [Tell if linear, logical, and goal-directed or not] - Thought Content: [Tell if any delusions or obsessive thoughts reported. Tell if any suicidal or homicidal ideation] - Perception: [List any hallucinations or illusions reported] - Insight: [Tell if it's intact or not] - Judgment: [Tell if it's good or not] - Cognition: [List any apparent cognitive deficits]

Other objective data

- Results of clinical measurements: N/A - Relevant information from other medical records: N/A - Summaries of official reports provided by other members in the treatment group: null.

Assessment

Case Formulation: [What was implicated in current session discussion and interaction; how to understand the patient’s problem and personality] Engagement and Progress: [patient’s level of engagement; reports of progress, symptom improvements, and prognosis. Intervention: [List techniques used, e.g., Empathy; Explanation; Relaxation exercises; Psychoeducation. Detail specific interventions applied during the session].

Assessment

Case Formulation: [What was implicated in current session discussion and interaction; how to understand the patient’s problem and personality] Engagement and Progress: [patient’s level of engagement; reports of progress, symptom improvements, and prognosis. Intervention: [List techniques used, e.g., Empathy; Explanation; Relaxation exercises; Psychoeducation. Detail specific interventions applied during the session].

Issues not addressed in the current session

[Issues not addressed]

Time for the next session

[Next session time]

Assigned homework

[Homework assignments]

Plan for the next session

[Plan for the next session]

Extra

Risk Assessment: [Details on any risk assessments conducted, e.g., suicidal ideation, harm to others.]