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CBT Progress Notes Template

Description:

This template is designed for documenting ongoing CBT therapy sessions, capturing the progress, interventions, and plans for each session. It provides a structured format to track the client's thoughts, behaviors, and emotions, as well as the therapist's observations and the treatment plan.

Note:

This template is for regular CBT sessions following the initial assessment. Adjust sections based on the session's focus and the client's needs.

Date: [Record the date of the session]

Session Number: [Note the session number in the sequence of therapy]

Client Name: [Enter the client’s full legal name]

Therapist Name: [Enter the therapist’s full name]

Duration: [Note the length of the session in minutes]

Attendance and Participation

[Note if the client was present and on time, any notable behaviors or engagement levels, such as active participation, distractibility, or emotional state.]

Agenda Setting

[List the items discussed or to be discussed, as agreed upon at the beginning of the session, to keep the session focused and structured.]

Review of Homework

[Summarize the homework assigned in the previous session, including what was completed, any challenges or successes, and how it relates to the client's goals or issues.]
[Note any feedback or adjustments made to the homework or the client's understanding of it.]

Current Issues and Symptoms

[Describe any new or ongoing issues the client is facing, including specific examples of thoughts, feelings, and behaviors that are problematic.]
[Note any changes in the frequency or intensity of symptoms since the last session.
[If applicable, record any scores from standardized measures used to track symptom severity.]

Interventions and Techniques Used

[Detail the specific CBT techniques or strategies used during the session, such as cognitive restructuring, behavioral activation, exposure therapy, or relaxation training.]
[For each intervention, describe how it was applied, the client's response, and any insights gained.]

Case Example or Specific Incident

Situation: [Describe the specific situation or event that the client identified as problematic.]
Automatic Thoughts: [Record the client's automatic, often negative, thoughts related to the situation.]
Emotions: [Note the emotions the client experienced in response to the thoughts and situation.]
Behaviors: [Describe the behaviors the client engaged in as a result of these thoughts and emotions.]
Challenging Thoughts: [Document the process of challenging the automatic thoughts, including the questions or techniques used to evaluate their accuracy or helpfulness.]
Alternative Thoughts: [List any alternative or more balanced thoughts that were developed to replace or modify the automatic thoughts.]
New Emotions and Behaviors: [Note any changes in the client's emotional response or planned behaviors based on the new, more balanced thoughts.]

New Homework Assignment

[Specify the homework or tasks assigned for the client to complete before the next session, such as monitoring thoughts, practicing new behaviors, or engaging in specific activities.]
[Explain the purpose of the homework and how it relates to the session's content or the client's goals.]

Summary and Next Steps

[Summarize the key points discussed in the session and any progress made toward the client's goals.]
[Outline the plan for the next session, including any specific topics to cover, techniques to use, or goals to achieve.]

Mood and Symptom Tracking

Beginning of Session: [Record the client's self-reported mood or symptom severity rating (0-10).]
End of Session: [Record the client's self-reported mood or symptom severity rating (0-10) at the end of the session.]

Therapist's Observations and Impressions

[Record any observations about the client's presentation, such as mood, affect, or body language, that may not have been directly discussed but are relevant to understanding their state.]
[Note any impressions or hypotheses about the client's issues or the effectiveness of the interventions, which can guide future sessions.]
[Document any adjustments to the treatment plan or concerns that need to be addressed in future sessions.]