CBT-E Clinical Note

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.)