**Session Details:**
[document the date, time, setting, and duration of the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single line.)
[describe the type of session, such as initial assessment or trauma-focused CBT] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single line.)
**Presenting Concerns:**
[describe the main trauma-related symptoms the patient is experiencing, such as re-experiencing, avoidance, hyperarousal, or negative cognitions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[provide a brief, non-graphic context of the patient's trauma history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Identified Cognitions and Biases:**
[document automatic thoughts expressed by the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[identify and describe cognitive distortions or biases, such as overgeneralization, catastrophizing, or self-blame] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[describe core beliefs or schemas identified, such as defectiveness, mistrust, danger, or vulnerability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[include impactful or recurring quotes from the patient that reflect cognitive themes or emotional patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Present as short verbatim quotes in quotation marks.)
**Emotional and Physiological Responses:**
[describe the patient’s affect and observable emotional state during the session, such as anxiety, shame, anger, or dissociation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[identify internal or external triggers discussed that contribute to emotional or physiological responses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[document somatic markers or physical sensations described by the patient in relation to trauma-related experiences] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**Mental Status / Observations:**
[describe any relevant observations of the patient's presentation including appearance, speech, motor behaviour, eye contact, dissociation, emotional responsiveness, or psychomotor agitation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**Therapeutic Process and Techniques:**
[describe psychoeducation provided, including explanation of trauma model or the link between thoughts, feelings, and behaviours] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[detail grounding or stabilization techniques used, such as sensory exercises, breathing retraining, or orienting to present] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[explain cognitive techniques employed during the session, such as Socratic questioning, cognitive restructuring, or identifying hot thoughts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[describe schema-focused interventions used, such as linking past experiences to current beliefs or schema identification work] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[document any behavioural experiments or in vivo exposure tasks introduced, attempted, or planned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[describe any safety planning discussions or interventions implemented] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Risk and Safety:**
[document any expressions of risk, suicidal ideation, self-harm urges, dissociative episodes, or current safety concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[describe steps taken to assess or manage risk, including safety planning, referrals, or escalation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
**Patient Strengths and Coping:**
[identify protective factors such as social supports, internal strengths, values, or helpful coping strategies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[describe previously used strategies that the patient has found effective, such as community involvement, spiritual practices, or creative expression] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**Therapist Reflections / Countertransference:**
[document the therapist's personal emotional response to the patient’s presentation or content] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in reflective paragraphs.)
[describe areas of uncertainty or stuck points in case formulation or therapeutic direction] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in reflective paragraphs.)
[list questions for supervision, such as decisions on pacing, therapeutic alliance, or avoidance management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
**Plan / Next Steps:**
[outline any homework tasks agreed upon, such as cognitive exercises, diary work, or grounding techniques] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[describe the planned focus or agenda for the next session, such as cognitive restructuring, schema mapping, or imaginal exposure] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
[document any planned coordination of care or external referrals] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in bullet points using "-".)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
