CBT-T Clinical Note

CBT-T Session Note Date: [Session date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Session #: [Session number within the course of CBT-T treatment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Treatment Stage: [Current CBT-T treatment stage or phase] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Focus Module (if used): [Specific CBT-T module or focus area addressed in this session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Scores: [Outcome measures used and corresponding scores] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) [Other measures and comparative scores] (Document any additional outcome measures or comparison with previous scores] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Session Focus [Brief summary of the primary therapeutic goals and focus areas for this session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as one concise sentence.) --- Client Update Eating behaviour since last session: [Summary of eating behaviours, patterns, or changes since the previous session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Emotional state: [Reported emotional state, mood, or affect since the last session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Progress with food changes: [Progress, difficulties, or adherence related to agreed food or eating changes] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Therapy-interfering behaviours: [Behaviours that interfered with engagement, attendance, or therapeutic tasks] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Body image concerns: [Body image-related thoughts, distress, or behaviours reported] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Weight discussion: [Details of any discussion related to weight, weighing, or weight-related concerns] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Summary of Session Check-in: [Summary of key updates provided by the client and/or parents or carers at the start of the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Weight & Health: [Discussion of weight trends, physical health, or medical monitoring] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Clinical Observations [Clinician observations of engagement, affect, behaviour, interaction style, and family dynamics where present] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Keep descriptive and non-interpretive.) --- Formulation / Reflections [Reflections on eating disorder voice strength, insight, motivation, engagement, and maintaining factors] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Therapist Process Notes Engagement: [Observations regarding the client’s engagement and participation in therapy] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Therapist stance: [Description of therapeutic stance or approach used during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Obstacles/alliance ruptures: [Any difficulties, ruptures, or challenges to the therapeutic alliance] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Use of formulation: [How the formulation was referenced or applied during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Tasks & Interventions [List of therapeutic tasks or interventions delivered during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Use bullet points.) • Agenda items: [Agenda items agreed or addressed during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Review of food plan and behaviour change: [Details of review of food plan adherence and behaviour change] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Psychoeducation: [Psychoeducational content delivered] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Behavioural strategies: [Behavioural strategies introduced or practised] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Body image work: [Body image-focused interventions used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Formulation used: [Details of formulation use during interventions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Therapy-interfering behaviours addressed: [Interventions targeting therapy-interfering behaviours] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Homework reviewed: [Review of previously assigned homework tasks] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Plan for Next Session • [Planned therapeutic focus or task for the next session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • [Additional planned focus or intervention] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • [Further planned focus if applicable] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Next Appointment: [Next scheduled appointment date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Focus: [Planned focus for the next session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Homework Tasks: [Homework tasks agreed for completion between sessions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Observation targets: [Specific behaviours, thoughts, or experiences the client is asked to observe] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Risk & Safety Risk behaviours or health concerns: [Identified risk behaviours, safety concerns, or health risks] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Action taken: [Actions taken in response to risk or safety concerns] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)