Psychotherapist Template

CBT-T Clinical Note

A professional Psychotherapist template for healthcare professionals.

About this template

Streamline your psychotherapy documentation with the CBT-T Clinical Note template, specifically designed for Cognitive Behavioral Therapy for Eating Disorders (CBT-T). This comprehensive template helps psychotherapists meticulously record session details, client updates on eating behaviours and emotional states, and crucial body image discussions. Efficiently document clinical observations, therapeutic formulations, and detailed intervention strategies, including psychoeducation and behavioural techniques. Heidi, your AI medical scribe, intelligently populates this template with relevant information from your consultations, ensuring every aspect of your CBT-T session, from homework assignments to risk assessments, is captured accurately and comprehensively. Perfect for mental health professionals focusing on eating disorder recovery.

Preview template

CBT-T Session Note Date: 1 November 2024 Session #: 6 Treatment Stage: Middle Phase Focus Module (if used): Body Image Disturbance Scores: EDE-Q: Current 3.2 (Previous 3.8); BDI-II: Current 18 (Previous 22) --- Session Focus The primary therapeutic goals for this session were to review progress on increasing meal variety and to address emerging body image concerns related to recent weight restoration. --- Client Update Eating behaviour since last session: Client reports successfully incorporating two new foods into her weekly meal plan, specifically wholemeal bread and nuts, which she previously avoided. She notes reduced anxiety around meal times but still struggles with spontaneous eating. Emotional state: Client reports feeling generally more stable emotionally, with fewer depressive episodes. However, she expressed increased anxiety and self-consciousness about her body shape after trying on new clothes. Progress with food changes: Good adherence to the agreed food plan, with particular success in increasing portion sizes and variety. She did express some difficulty adhering to the snack schedule on busy days. Therapy-interfering behaviours: No significant therapy-interfering behaviours reported or observed this week. Client arrived on time and completed all assigned tasks. Body image concerns: Client reported significant distress regarding perceived changes in her body shape, particularly her abdomen. She spent more time checking her appearance in the mirror and comparing herself to others. Weight discussion: Weight was discussed in the context of recent restoration and its impact on body image. The client acknowledged the necessity of the weight gain for her physical health but expressed ambivalence emotionally. --- Summary of Session Check-in: Client reported a good week overall, with improvements in energy levels and reduced preoccupation with food, but highlighted increasing concerns about her body image. Parents reported observing the client engaging more in family meals. Weight & Health: Client's physical health remains stable. Weight trajectory is appropriate, indicating continued restoration. No acute medical concerns were identified. --- Clinical Observations Client presented with good eye contact and was generally engaged, though she became visibly distressed and tearful when discussing body image concerns, demonstrating fidgeting and a slumped posture. Family dynamics observed were supportive, with parents actively listening and offering reassurance. --- Formulation / Reflections Client continues to demonstrate good insight into the necessity of weight restoration for physical health, though the 'eating disorder voice' appears to be strengthening in the area of body image. Motivation for recovery remains high, but body image distress is now a significant maintaining factor that requires focused intervention. --- Therapist Process Notes Engagement: Client was highly engaged and forthcoming, particularly during the discussion of body image, despite evident distress. Therapist stance: A compassionate and validating stance was maintained, particularly when addressing the client's body image distress, while gently challenging unhelpful cognitive distortions. Obstacles/alliance ruptures: No significant obstacles or alliance ruptures occurred during the session. Use of formulation: The formulation was used to explain how weight restoration can trigger increased body image concerns, normalising the client's experience and linking it to the eating disorder's compensatory mechanisms. --- Tasks & Interventions • Agenda items: Review of meal plan adherence, discussion of body image concerns, introduction to cognitive restructuring for body image thoughts. • Review of food plan and behaviour change: Reviewed successful integration of new foods and brainstormed strategies for consistent snacking on busy days. • Psychoeducation: Provided psychoeducation on typical body changes during weight restoration and the concept of 'body neutrality' as a stepping stone to positive body image. • Behavioural strategies: Practised 'mirror exposure with compassionate self-talk' to reduce body checking behaviours. Assigned mindful eating exercise for one meal daily. • Body image work: Introduced cognitive restructuring techniques to challenge negative automatic thoughts about body shape and size. • Formulation used: Explained how the eating disorder uses body image concerns to maintain its hold, highlighting the importance of challenging these thoughts as part of recovery. • Therapy-interfering behaviours addressed: None explicitly addressed as none present. • Homework reviewed: Reviewed success in food variety and discussed challenges with spontaneous eating. --- Plan for Next Session • Continue body image work, focusing on identifying and challenging core beliefs about appearance. • Explore emotional regulation strategies for managing body image distress. • Review mindful eating practice and address any ongoing mealtime anxieties. Next Appointment: 8 November 2024 Focus: Deepening body image interventions and emotional regulation. --- Homework Tasks: Practice cognitive restructuring for negative body image thoughts (3 times daily); continue mindful eating for one meal; engage in 'mirror exposure with compassionate self-talk' for 5 minutes daily. Observation targets: Observe frequency and intensity of body checking behaviours; notice situations or thoughts that trigger body image distress. --- Risk & Safety Risk behaviours or health concerns: No acute risk behaviours identified. Body image distress is a concern but client reports no intent for compensatory behaviours or self-harm. Action taken: Reinforced safety plan if body image distress becomes overwhelming. Emphasised open communication regarding any urges or concerns.

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.)

Browse more templates

Use this template