Psychotherapist Template

Generic CBT Session Note

A professional Psychotherapist template for healthcare professionals.

About this template

Streamline your clinical record-keeping with our Generic CBT Session Note template, perfect for psychotherapists, counsellors, and mental health professionals. This comprehensive template is meticulously designed to capture all essential details of a Cognitive Behavioural Therapy session, from client updates and agenda setting to specific cognitive and behavioural interventions. Easily document Socratic questioning, thought records, behavioural experiments, and homework assignments, ensuring a thorough and organised account of each session. Ideal for maintaining high standards of documentation, this template helps track client progress, therapeutic processes, and risk assessments. With Heidi, this template intelligently populates from your session transcripts, saving valuable time and ensuring accuracy in every CBT progress note example.

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CBT Session Note Client name: Jane Doe, Session date: 1 November 2024, Session number: 7 Therapist: Dr. Emily White, Clinical Psychologist --- Session focus Addressing negative automatic thoughts related to social anxiety in public speaking situations. CBT model used: Beckian Cognitive Therapy --- Client update - Mood and symptom check-in: Client reported moderate anxiety (7/10 at times) when thinking about an upcoming presentation, improved from severe (9/10) last week. Mood generally low-moderate (5/10), feeling more hopeful after last session's discussion. - Recent events: Client had a minor disagreement with a colleague at work, which triggered feelings of inadequacy and exacerbated her fear of being judged during her presentation. - Homework review: Client completed the thought record on one occasion, identifying distorted thoughts about her ability to deliver the presentation. She found it helpful in challenging some negative predictions but struggled to fully reframe them into balanced thoughts. --- Agenda - Agenda set collaboratively: Yes. Agenda items: Review homework, explore recent trigger, practice cognitive restructuring for presentation anxiety, plan behavioural experiment. - Items prioritised: Cognitive restructuring techniques for public speaking anxiety and developing a plan for a behavioural experiment. - Time managed well: Time was managed effectively, focusing on the prioritised items. One minor item, discussing sleep patterns, was deferred to the next session. --- Cognitive interventions - Socratic questioning used: Yes. Explored client's core beliefs about her competence and the need for external validation, linking these to her fear of judgment during public speaking. Challenged the belief that a single mistake equals complete failure. - "Guided discovery": Used guided discovery to help the client identify alternative interpretations of her colleague's feedback, moving from self-blame to a more balanced view of the interaction. - Thought records / experiments: Utilised a thought record to break down the client's catastrophic thoughts about her upcoming presentation. Situation: Imagining giving the presentation. Thoughts: "I'll forget my lines, everyone will laugh, I'm going to humiliate myself." Observed outcomes: Increased anxiety, avoidance urges. Collaboratively challenged these thoughts, identifying evidence for and against, and generated more balanced alternatives: "I am prepared, a few mistakes are normal, I can recover if I stumble." --- Behavioural interventions - Behavioural experiment or activity scheduling: Planned a graded behavioural experiment: practicing a section of her presentation in front of a mirror, then a trusted friend, followed by a small internal team meeting. Intended behaviour change: gradually exposing herself to public speaking situations to challenge her fear of negative evaluation. - "Homework planning": Yes. Homework included completing another thought record on presentation anxiety and practicing the first step of the behavioural experiment (mirror practice). - Avoidance or safety behaviours addressed: Discussed client's tendency to avoid practising her presentation and to rely heavily on detailed notes as a safety behaviour. Explored the long-term impact of these behaviours on her confidence. --- Therapeutic process - Collaboration and structure: Strong collaboration, client actively participated in setting the agenda and exploring thoughts. Session followed a clear CBT structure, moving from check-in to intervention and homework planning. - Use of formulation: Linked client's current anxiety to her historical experiences of criticism and the development of core beliefs about inadequacy, using a basic cognitive model to explain maintenance cycles. - Therapist style: Therapist maintained a collaborative, empathetic, and gently challenging stance, encouraging client autonomy and self-discovery. - Client insight or shifts: Client demonstrated significant insight into the link between her negative automatic thoughts and her anxiety symptoms. She expressed a shift in perspective regarding the possibility of managing her presentation anxiety, stating, "I can see how my thoughts are making it worse, and maybe I can actually change them." --- Homework - Task assigned: 1. Complete a thought record for any instance of presentation-related anxiety. 2. Practice her presentation in front of a mirror for 10 minutes, noting down any challenging thoughts or feelings. - Rationale shared: Discussed how thought records help to identify and challenge unhelpful thinking patterns, and how mirror practice can build confidence and desensitise her to the act of speaking. - Troubleshooting discussed: Anticipated potential difficulty with self-criticism during mirror practice; discussed focusing on self-compassion and observing thoughts rather than engaging with them. --- Next session - Planned focus: Review behavioural experiment and thought record, continue cognitive restructuring for public speaking, potentially move to the next stage of the behavioural experiment. - Any adaptations: None planned at this time, maintain current pace. --- Risk and safety - Risk check: No new risk concerns or disclosures. Client reports stable mood overall, despite anxiety related to the presentation. Denied any thoughts of self-harm or harm to others. - Protective factors discussed: Discussed client's supportive partner and her motivation to overcome this anxiety to advance her career as strong protective factors. - Action taken: N/A, no risk or safety concerns requiring immediate action.

CBT Session Note [Client name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), [Session date] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.), [Session number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) Therapist: [Therapist name and role] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Session focus [Main therapeutic target, problem, or theme addressed during this session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write as a brief statement.) CBT model used: [Specific CBT model or framework applied in this session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Client update - Mood and symptom check-in: [Client-reported mood, distress level, symptom severity, or changes since last session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Recent events: [Recent triggers, stressors, life events, or behavioural and emotional reactions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Homework review: [Review of previously assigned homework, including completion and reflections] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Agenda - "Agenda set collaboratively": [Whether the agenda was set collaboratively and any agenda items agreed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. If included, state Yes or No and list items if applicable.) - Items prioritised: [Topics or issues prioritised by client and therapist] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Time managed well: [Observations regarding time management, deferred items, or agenda difficulties] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Cognitive interventions - Socratic questioning used: [Whether Socratic questioning was used and the key beliefs, assumptions, or distortions explored] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - "Guided discovery": [Details of guided discovery techniques used] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Thought records / experiments: [Use of thought records or cognitive experiments, including situation, thoughts, and observed outcomes] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Behavioural interventions - Behavioural experiment or activity scheduling: [Behavioural experiments or activity scheduling planned or reviewed and intended behaviour change] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - "Homework planning": [Whether homework was collaboratively planned and details of the planned behavioural change] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Avoidance or safety behaviours addressed: [Avoidance patterns or safety behaviours explored and how these were addressed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Therapeutic process - Collaboration and structure: [Observations of collaboration, structure, and session flow] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Use of formulation: [Use of formulation, including links to CBT model or maintenance cycles] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Therapist style: [Therapist stance, style, or approach used during the session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Client insight or shifts: [Notable insights, shifts in perspective, or changes in attitude reported or observed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Homework - Task assigned: [Homework tasks assigned for completion between sessions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Rationale shared: [Whether the rationale for homework was discussed and understood] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Troubleshooting discussed: [Barriers, anticipated difficulties, or supports discussed in relation to homework] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Next session - Planned focus: [Planned therapeutic focus or goal for the next session] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Any adaptations: [Any planned adaptations to approach, pacing, or alliance work] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) --- Risk and safety - Risk check: [Any risk assessment, disclosures, or safety check completed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.) - Protective factors discussed: [Protective factors, coping strategies, or supports discussed] (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, such as safety planning or liaison] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely.)

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