DBT session note

1. Diary Card Review- Life Threatening Behaviours- [note any behaviours reported by the client, or observed by the therapist, that could potentially cause harm to life or health, such as suicidality, deliberate self-harm, dietary restriction, binge-eating, vomiting, laxative use, over-exercise, deliberately not taking prescribed medications, disobeying medical advice, or any noted medical instability discussed in the transcript. Note how many times of the day or days out of the week that the client engaged in life threatening behaviours.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Therapy Interfering Behaviours- [note any behaviours reported by the client, or observed by the therapist, that could potentially negatively influence the therapeutic relationship, such as not using coaching calls when indicated, arriving late to individual or group skills sessions, skipping individual or group skills sessions, being willful versus willing in using skills, not completing diary cards before session, refusing to act on suggestions as to how to handle situations. Note how many times of the day or days out of the week that the client engaged in therapy interfering behaviours.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Quality-of-Life Interfering behaviours- [note any behaviours reported by the client or observed by the therapist that could potentially interfere with building quality of life. Note how many times out of the day or days out of the week that the client engaged in quality-of-life threatening behaviours.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Top targets for behaviour change- [list any targets for behaviour change observed by client or therapist in bullet point format. Indicate if the client or therapist identified this target.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Solution- [list any solutions for the top targets identified by the client or therapist in bullet point format.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Plan- [list any action steps for the identified solutions in bullet point format.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Urges to quit- [If the client identifies any urges to quit DBT, please summarize them in paragraph format.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) Effectiveness- [if the client identifies being able to use DBT skills for any life events in the past week, summarize them here in paragraph format. If the therapist identifies for the client that they used DBT skills for any life event, summarize them here in paragraph format. Note how many times of the day, or days out of the week that the client used DBT skills.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) 2. Review of modes of treatment- [list in checklist format if the client attended individual therapy sessions, group skills training session and if they used coaching calls in an appropriate manner. ] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) 3. Intervention- [please include a paragraph summarizing presenting issue and intervention used, categorized by presenting issue or by Life Threatening Behaviour, Therapy Interfering Behaviour, or Quality-of-life interfering behaviour.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely) 4. Risk- [please include a standard risk assessment.] (only include if explciitly mentioned in the transcript, context or clinical note; else omit completely) 5. Plan- [list assigned homework here in bullet point format. List issues that the client and therapist will work on next session, if any are identified.] (only include if explicitly mentioned in the transcript, context or clinical note; else omit completely)