Generic CBT Session Note

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.)