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Counselors Template

DBT (Dialectical Behavior Therapy) Note

A professional Counselors template for healthcare professionals.
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Specialty

Counselors

Used

82 times

Type

Note

Last edited

02/12/2025

Created by

Samantha Redd

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About this template

This DBT Therapy Note template is designed for counselors to document Dialectical Behavior Therapy sessions effectively. It includes sections for recording the client's mood, participation in mindfulness exercises, and engagement in psychoeducation. The template also allows for detailed documentation of the clinician's interventions and homework assignments. Ideal for mental health professionals, this template ensures comprehensive and structured notes, enhancing the therapeutic process and client progress tracking. Use this template with Heidi, the AI medical scribe, to streamline your documentation and focus more on client care.

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Symptom Description and Subjective Report The client, a 28-year-old female, presented with a low mood and reported feeling overwhelmed by daily stressors. She appeared anxious and had difficulty maintaining eye contact. During the session, the client participated in mindfulness exercises, though she expressed initial reluctance. She was guided through a breathing exercise and reported feeling slightly more relaxed afterward. The client did not complete the assigned homework from the previous session, citing a lack of time and motivation. In psychoeducation, the client engaged actively, asking questions about emotional regulation techniques. Objective Content The clinician introduced a mindfulness exercise focused on deep breathing and grounding techniques. The client was encouraged to focus on her breath and the sensations in her body. The homework review revealed that the client had not attempted the assigned tasks, which included journaling her emotions. The psychoeducation content covered the basics of emotional regulation and distress tolerance skills. The clinician assigned new homework, which involved practicing the breathing exercise daily and journaling her experiences. Interventions Used - Mindfulness breathing exercise - Psychoeducation on emotional regulation - Homework assignment: daily mindfulness practice and journaling

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  • Médecine spécialisée

  • Paramédical

  • Psychologie et psychiatrie

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