GIRP NOTE
Client: [Name or ID]
Date of service: [Date]
Start and end time: [Times and total minutes]
Service: [Individual counseling, family session, case management contact, or skills session]
Location and format: [Office, home, school, community site, or residential unit; in person, video, or phone]
Others present: [Name and relationship, or none]
Provider: [Name, credentials, role]
GOAL
Treatment plan goal: [Goal number and wording from the current plan]
Objective: [Objective number, its measure, its target, and its target date]
Status at start: [Last score, count, or rating on this objective, and its date]
Client's words: [What the client said about the goal, or wanted from today]
Session focus: [The part of the goal this session worked on]
INTERVENTION
Techniques and services: [Each one by name: skills teaching, rehearsal, motivational interviewing, problem-solving, psychoeducation, linkage to a resource]
Link to the objective: [How each one serves the objective above]
Materials and contacts: [Worksheets, handouts, calls made, or referrals given in the session]
RESPONSE
Engagement: [Participation, openness, and understanding]
Presentation: [Brief mental status: appearance, behavior, mood in the client's words, affect, thought process]
Measured result: [Today's score, count, rating, or skill shown, beside the previous one]
Progress on the objective: [Met, progressing, no change, or setback, with the evidence]
Risk screen: [Suicidal thoughts, self-harm, harm to others, substance use: what you asked, the answers, and any action]
PLAN
Client steps: [What the client will do before the next contact, specific enough to count]
Provider tasks: [Calls, referrals, or coordination, with consent and a due date]
Next focus: [The goal and objective for the next session, and why]
Plan status: [No change, objective updated, plan review due, or level of care change]
Next contact: [Date, time, location, and format]
Signed: [Name, credentials, date and time]