Trauma-Focused Therapy Note Template
Description:
This template is designed for documenting sessions in trauma-focused therapy, providing a structured format to track the client's progress, the interventions used, and the plans for future sessions. It focuses on the safety, stabilization, and processing of traumatic experiences.
Note:
This template is for general therapy sessions in trauma-focused therapy. 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]
Check-in
[Briefly note how the client is feeling at the start of the session, any recent triggers or stressors, and their current emotional state.]
[Assess the client's safety, including any thoughts of self-harm or harm to others.]
Review of Previous Session and Homework
[Summarize the main points from the last session.]
[Review any homework or tasks assigned, including what was completed, any challenges or successes, and how they relate to the client's trauma recovery.]
Current Focus and Topics Discussed
[Describe the main issues or areas of focus for this session, such as stabilization, processing a specific memory, or building coping skills.]
[Note any specific trauma-related concepts or principles discussed.]
Trauma Symptom Assessment
[Provide a narrative description of any trauma-related symptoms the client is experiencing, such as flashbacks, nightmares, dissociation, or hypervigilance.]
[Note any changes in symptom frequency or intensity since the last session.]
Interventions and Techniques Used
[Detail the specific trauma-focused techniques or exercises used during the session, such as EMDR, CBT for PTSD, grounding techniques, or relaxation exercises.]
[For each intervention, describe how it was applied, the client's response, and any insights gained.]
Strengths and Resources
[Identify and note the client's strengths that were evident or utilized during the session.]
[Discuss any new strengths discovered or how existing strengths are being applied to current challenges related to trauma.]
Goals and Progress
[Review the client's current goals for trauma recovery and how they are progressing towards them.]
[Note any adjustments to goals or new goals set during the session.]
Plan for the Next Session
[Outline the plan for the next session, including any specific topics to cover, techniques to use, or goals to achieve.]
[Assign any homework or tasks for the client to complete before the next session, such as practicing grounding techniques or journaling about specific experiences.]
Standardized Measures
[If applicable, record any scores from standardized trauma measures used to track the client's progress, such as the PTSD Checklist (PCL) or the Impact of Event Scale-Revised (IES-R).]
Therapist's Observations and Impressions
[Record any observations about the client's presentation, such as their mood, affect, or body language, that are relevant to their trauma experience.]
[Note any impressions or hypotheses about the client's trauma symptoms 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.]
Trauma-Focused Therapy Note Template (Filled Mock Session)
Date: April 5, 2025
Session Number: 3
Client Name: David Brown
Therapist Name: Dr. Anna Patel
Duration: 60 minutes
Check-in
David reports feeling somewhat anxious this week due to the upcoming anniversary of his trauma. He has been experiencing more frequent nightmares and some dissociation during the day. He confirms he is safe and has no thoughts of self-harm.
Review of Previous Session and Homework
The last session focused on practicing grounding techniques to manage dissociation. David completed his homework of practicing these techniques daily and found them helpful in reducing the duration of dissociative episodes.
He shared that he used the "5-4-3-2-1" method during a stressful work meeting and it helped him stay present.
Current Focus and Topics Discussed
This session focused on preparing for the anniversary of the trauma. We discussed potential triggers and how to manage them.
David and I also started to explore the possibility of processing a specific traumatic memory in future sessions.
Trauma Symptom Assessment
David has been experiencing increased nightmares (3 nights this week, up from 1 last week). He also reports more frequent intrusive thoughts about the trauma.
His dissociation episodes have slightly increased in frequency but are shorter in duration due to the grounding techniques.
Interventions and Techniques Used
We used a psychoeducation approach to discuss common reactions around trauma anniversaries.
We practiced a relaxation exercise to help manage anxiety.
We also began to map out a safety plan for the anniversary week.
Strengths and Resources
David's strength in perseverance is evident as he continues to practice his coping skills despite increased symptoms.
He has a supportive partner who is aware of the anniversary and is helping him manage his schedule to reduce stress.
Goals and Progress
David's goal is to manage his symptoms during the anniversary week without significant disruption to his daily life.
He is making progress in using his coping skills and is more confident in handling his symptoms.
Plan for the Next Session
The next session will focus on continuing to prepare for the anniversary and possibly beginning to process a specific memory if David is ready.
Homework: David will continue practicing grounding techniques and will write down any specific thoughts or feelings he has as the anniversary approaches.
Standardized Measures
IES-R score: 35 (moderate to severe symptoms), up from 30 last session.
Therapist's Observations and Impressions
David is showing increased anxiety and symptoms as the anniversary approaches, which is expected.
He is actively engaging with his coping strategies and seems to have a good support system.
It's important to monitor his symptoms closely and adjust the treatment plan if needed.