Psychotherapist Template

CBT-E Clinical Note

A professional Psychotherapist template for healthcare professionals.

About this template

Enhance your psychotherapeutic practice with this comprehensive CBT-E Clinical Note template. Specifically designed for Cognitive Behavioural Therapy for Eating Disorders (CBT-E) sessions, this template is ideal for psychotherapists, clinical psychologists, and mental health professionals specialising in eating disorder treatment. Efficiently document key session details, client updates on eating behaviours, emotional states, and progress with self-monitoring. Track interventions, homework assignments, and therapeutic reflections with dedicated sections for collaboration, engagement, and therapist style. This template streamlines your documentation, ensuring all crucial aspects of a CBT-E session are captured, providing a clear record of treatment progression and client care. Heidi, your AI medical scribe, can intelligently populate this template from your session transcripts, saving you valuable time.

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Psychotherapist Clinical Note CBT-E Clinical Session Note Session #: 8 Stage of Treatment: Core Modules Model: Fairburn Modules in Use: Regular Eating, Addressing Dietary Restraint, Body Image Concerns Questionnaires Reviewed: EDE-Q (score 3.5, decreased from 4.1 last session), BDI-II (score 18, stable) --- Session Focus The session focused on further challenging dietary rules and exploring the client's fear of weight gain, linking it to underlying self-worth beliefs. --- Client Update Eating behaviours since last session: Client reported increased regularity with meals, managing to stick to planned meal times on 5 out of 7 days. Restriction remains a challenge, particularly with 'fear foods', but no reported bingeing or compensatory behaviours. Emotional state and mood: Mood has been moderately stable, with occasional dips related to body dissatisfaction. Client identified triggers as social media comparison and fitting into certain clothes. Weight and weighing: Client engaged in weekly weighing as agreed and discussed her anxiety surrounding the number. She noted a slight increase but was able to process it with therapist support, linking it to normal fluctuations rather than failure. Self-monitoring: Self-monitoring was completed diligently, providing clear insights into patterns of eating and associated thoughts/feelings. Client demonstrated improved ability to identify triggers for unhelpful eating behaviours. Events impacting eating or mood: Client reported an argument with a friend which temporarily impacted her mood and adherence to regular eating, but she was able to recover quickly with self-compassion. --- Summary of Session Check-in: Client reported a challenging but productive week, highlighting progress in regular eating alongside ongoing struggles with body image and fear foods. Parents reported positive observations of client's mood and increased engagement at family meals. Weight & Health: Client's weight was stable this week, and discussion focused on separating weight from self-worth. --- Tasks & Interventions • Agenda items: Review of self-monitoring, challenging dietary rules, body image work. • Self-monitoring reviewed: Thorough review of completed self-monitoring forms, highlighting progress in regular eating and identifying areas for further intervention regarding fear foods. • Cognitive techniques: Guided discovery used to challenge the client's 'all-or-nothing' thinking regarding food and body image. Evaluation of rules around specific 'forbidden' foods was initiated. • Behavioural strategies: Continued reinforcement of regular eating patterns. Planned exposure task for a 'fear food' (chocolate) to be initiated this week. • Work on formulation: Reviewed the client's current formulation, specifically the link between strict dietary rules and body image concerns, and how these maintain her eating disorder. • Module content addressed: Focused on Module 4: Addressing Dietary Restraint and aspects of Module 6: Body Image Concerns. • Homework reviewed: Reviewed the previous week's homework of consistently eating three meals and two snacks, noting 70% adherence. --- Therapist Process Notes Collaboration and engagement: Client was highly collaborative and engaged throughout the session, openly discussing difficulties and insights. Therapeutic alliance remained strong. Use of formulation or Socratic dialogue: Socratic dialogue was effectively used to help the client explore the irrationality of some of her core beliefs about food and body weight, and to develop alternative, more balanced perspectives. Therapist style/reflection: Maintained a compassionate yet directive stance, ensuring key CBT-E interventions were delivered whilst also validating the client's emotional experience. --- Plan for Next Session • Continue challenging dietary restraint and fear foods. • Further exploration of body image thoughts and development of coping strategies. • Reinforce self-monitoring for consistency. Next Appointment: 1 November 2024 Planned focus: Exposure to fear foods, body image work, and relapse prevention strategies. --- Homework Assigned tasks: Continue regular eating, complete planned exposure to chocolate, continue detailed self-monitoring, and record thoughts/feelings related to body image. Plan to review: Review self-monitoring, discuss experience of fear food exposure, and explore body image reflections. --- Risk & Safeguarding Risks disclosed or observed: No new risks or safeguarding concerns identified. Client reports reduced urges for compensatory behaviours. Action taken: Continued monitoring of eating behaviours and emotional state. Safety plan remains in place.

CBT-E Clinical Session Note Session #: [Session number within the course of CBT-E treatment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Stage of Treatment: [Current CBT-E stage] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Model: [CBT-E model used, such as Fairburn or Waller] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Modules in Use: [Specific CBT-E modules addressed during treatment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Questionnaires Reviewed: [Outcome measures reviewed, including scores and comparison with previous measures] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Session Focus [Brief summary of the key therapeutic themes and focus of 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 behaviours since last session: [Summary of eating behaviours including regularity, restriction, bingeing, or compensatory behaviours] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Emotional state and mood: [Mood trends, emotional state, and identified triggers] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Weight and weighing: [Whether weighing occurred and the client’s response or discussion around weighing] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Self-monitoring: [Completion, accuracy, engagement, and insights from self-monitoring] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Events impacting eating or mood: [Interpersonal stressors, life events, or changes affecting eating or mood] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Summary of Session Check-in: [Brief paragraph summarising key updates from the client and/or parents or carers] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Weight & Health: [Single sentence summarising weight trends or health-related discussion] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Tasks & Interventions [List of CBT-E 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 set or agreed during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Self-monitoring reviewed: [Outcome of self-monitoring review or intervention if not completed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Cognitive techniques: [Cognitive strategies used, such as guided discovery or evaluation of rules] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Behavioural strategies: [Behavioural strategies used, such as regular eating or exposure tasks] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Work on formulation: [How the formulation was developed, reviewed, or applied] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) • Module content addressed: [Specific module-related content covered] (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.) --- Therapist Process Notes Collaboration and engagement: [Observations of collaboration, engagement, and therapeutic alliance] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Use of formulation or Socratic dialogue: [Use of formulation or Socratic dialogue within the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Therapist style/reflection: [Reflections on therapist stance or style during the session] (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.) Planned focus: [Planned focus or target area for the next session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Homework Assigned 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.) Plan to review: [Items or tasks planned for review at the next session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Risk & Safeguarding Risks disclosed or observed: [Any risks or safeguarding concerns identified] (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 safeguarding concerns] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)

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