CBT SESSION NOTE

Client: [Name or ID]
Date of session: [Date]
Session: [Number in this course of CBT, such as 6 of 16; start and end time]
Format: [In person, video, or phone; client's location and privacy if remote]
Others present: [Name and role, or none]
Clinician: [Name, credentials]
Diagnosis and protocol: [Working diagnosis, and the CBT protocol or phase of treatment]
Treatment plan goal: [Goal and objective number, with the measure and target]

MOOD CHECK AND MEASURES
Measures today: [PHQ-9, GAD-7, or a disorder-specific scale: today's score, the last score, and the baseline]
Mood: [In the client's words, with a 0 to 10 rating if you use one]
Presentation: [Brief mental status: appearance, affect, thought process]
Risk check: [Suicidal thoughts, self-harm, harm to others, substance use: what you asked and the answers]

BRIDGE FROM LAST SESSION
Client's takeaway: [The main point of the last session, in the client's words]
Since last session: [Events, changes in symptoms, and anything the client wants to raise]

AGENDA
Items agreed: [Two or three items in order, and who raised each one]

HOMEWORK REVIEW
Task set: [The homework agreed at the last session]
Completion: [Done, partly done, or not done, and how often]
What the client learned: [Ratings, the prediction tested and its result, or what got in the way]

SESSION WORK
Target: [The situation, thought, or behavior worked on, and the plan goal it serves]
Technique: [Thought record, cognitive restructuring, behavioral activation, exposure, behavioral experiment, problem-solving, or skills practice]
Thought work: [Automatic thought and belief rating; feelings rated 0 to 100; evidence for and against; balanced thought; ratings after]
Behavioral work: [Activities scheduled with mastery and pleasure ratings, or the exposure step with the prediction and SUDS before, at the peak, and after]
Formulation update: [What today's work showed about beliefs, rules, avoidance, or safety behaviors]

SUMMARY
Client's summary: [The key point of the session, in the client's words]
Progress on the goal: [Improving, no change, or worse, with the evidence]

NEW HOMEWORK
Task: [What, when, how often, and how the client will record it]
Purpose: [The prediction it tests or the skill it builds]
Barriers planned for: [What might get in the way, and the plan for it]

FEEDBACK
Client feedback: [What helped, what didn't, and anything that bothered the client]
Changes for next time: [Adjustments to pace, focus, or the plan]

PLAN
Next session focus: [The item or step to take up next, and why]
Coordination: [Contact with a prescriber, physician, or others, with consent; or none]
Next session: [Date, time, and format]

Signed: [Clinician name, credentials, date and time]