Orthodontic Assessment

**CBT Session Note** [Client name], [Date], [Session number] Therapist: [Your name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Session focus [Main target/problem addressed this session – e.g. "rumination", "low mood", "social anxiety", "body image concerns", etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Client update - Mood and symptom check-in: [Client-reported mood, distress level, symptom severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Recent events: [Triggers, stressors, behavioural or emotional reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Homework review: [What was completed, what wasn’t, what was learned or avoided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Agenda - "Agenda set collaboratively": [Yes/No, if yes list agenda items] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Items prioritised: [List main topics agreed on by client and therapist] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Time managed well: [Note if needed more time, items deferred, or if agenda was difficult to follow] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Cognitive interventions - Socratic questioning used: [Yes/No – describe key distortions or beliefs explored and evidence of cognitive shifts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - "Guided discovery": [e.g. identifying automatic thoughts, exploring evidence and evidence of cognitive shifts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Thought records / experiments: [Outline situation, thought, result and evidence of cognitive shifts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Behavioural interventions - Behavioural experiment or activity scheduling: [Describe what was done or planned and how behaviour has changed or is planned to change] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - "Homework planning": [Yes/No – was it collaboratively agreed and achievable, and how behaviour has changed or is planned to change] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Avoidance or safety behaviours addressed: [Describe how these were confronted or explored and how behaviour has changed or is planned to change] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Therapeutic process - Collaboration and structure: [e.g. high engagement, passive, resistant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Use of formulation: [If relevant – referred to model, drew links, mapped vicious cycles] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Therapist style: ["Empathic", "structured", "active", "collaborative", "directive"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Client insight or shifts: [Describe any notable ‘aha’ moments or change in attitude] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Homework - Task assigned: [e.g. thought monitoring, behavioural experiment/change, journaling/making notes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Rationale shared: [Yes/No – was client clear on why this matters?] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Troubleshooting discussed: [If relevant – barriers, expected difficulty, support] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Next session - Planned focus: [What will be returned to or introduced next time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Any adaptations: [If relevant – changes in approach, addressing alliance, pacing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Risk and safety - Risk check: [e.g. suicidal ideation, self-harm, dissociation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Protective factors discussed: [If relevant – coping, supports, reasons for living] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Action taken: [Safety planning, GP contact, supervision consulted] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)