Note Stems
Therapist/Patient:
Assessed
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Client’s sx
Client’s progress
Challenged Statements regarding:
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Themselves
Progress made
Relationships
Family History
Perception
Thought related to
Personalized to
Demonstrated
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Mindfulness techniques of
Communication strategies of
Explored/Facilitated dialog
Onset of ..
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Sx that occurred
Incident that happened
Feelings related to
Evaluated
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Consequences certain axn
Benefit of choice
Identify/Relayed/Communicated
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Alt coping strategies
Triggers related to certain outcomes or
sx
Labeled
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Feelings
Triggers
Patterns
Behaviors
Normalized
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Experience of something
Feelings after experiencing x
Reflected
Processed
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Feelings related to event
Fear about x
Emotions related to a specific person
Template:
Pt reports ongoing (dx) anxiety/depressed mood/aggression/impulsivity. Intensity is rated as ___ on a scale of 0 to 10 with
0 indicating no observable symptoms or triggers. Pt indicated triggers to (dx) including ___.
Pt identified symptoms of (dx) including ___.
During the session, therapist ____ (reference treatment plan and interventions).
Words to use for client says:
Relayed, reports, states, communicated, identified, reported, expressed, shared, discussed, presents, disclosed,
admits/denies,
Words for therapist actions:
Led client in practicing, clarified, established connection between, normalized, problem solved, brainstormed, reframed,
reflected, summarized, modeled, monitored, assessed
Client talks alot about how good things are:
"Writer and client processed through events of past week and focused on positive elements in client's life. Client identified
several positive social supports in life and discussed current stressors"
“therapist reinforced positive changes or positive pro-social interactions and encouraged client to identify strategies used
to promote success. Client had difficulty verbalizing strategies used.” I tend to work with kiddos so they tend to have a
hard time and then I offer some suggestions like “you were working hard to listen to your teachers” or “you found a game
with other kids that you both liked.” And then I document “therapist verbalized skills and strategies used by client to
support client in identifying repeatable actions.”
Play therapy
“Client and therapist engaged in imaginative play to further explore family dynamics, identify areas of conflict, and
practice coping skills”
Fort. We built a fort, and they talked about how their siblings were terrible fort builders.
"Engaged client in practical applications of distress tolerance skills"
Kiddo got their tush handed to them in mario kart
Note: Clinician engaged client in a creative, interactive activity during which the Clinician and client each created a safe
space using a variety of objects. Clinician and client took turns verbalizing why they would feel safe in their safe space.
Reality: Clinician and client played Minecraft.
Engaged in creative play activity To reinforce the practice of self validation and self soothing skills while promoting
interpersonal effectiveness.
Client once fell asleep during a session:
Note: "Client engaged in self-care. Counselor held space to allow Client to engage in a self-care practice."
Note: Patient participated in therapeutic group activity to support the building of communication skills, practicing impulse
control, and exercising prosocial behavior.
Reality: We played Uno.
Play therapy was used to assist client in identifying and processing emotions. Client was able to express his difficulties in
communicating with other due to fear of not being understood. Client was educated on importance of communication
through role play activity
*reality playing roblox*
I've watched Star Trek with a client
Practiced the implementation of a distraction coping technique and observing different means of communication being
verbal and nonverbal and assertive versus passive versus passive aggressive
Yes! I use games like musical chairs, Simon says, and green light go/red light stop as “practicing impulse control”
My note today, writing and client spent time building rapport. Client was able to verbalize how she used distraction as
coping skill. We made jewelry LOL
I have played the game "Watch yo mouth" in group with adolescents with the documentation of "Promoting
awareness of the effects of communicating clearly and precisely." It's true.....inpatient recreational therapy was amazing
for honing this skill (recognizing therapeutic themes)
What would be some good ways to write that you helped a client process language/words they have heard from family
members that have caused them harm due to their identities?
Therapist assisted client in identifying triggers to their low self esteem.
Therapist helped client explore identity and make connections between presenting feelings of _______ & communication
and messages stemming from family
Client vented/processed for much of session:
Assisted patient in identifying and processing emotions. Patient effectively expressed difficulties in communication with
others due to fear of not being understood. Patient was educated on importance of communication through role play.
Focused on rapport building and processed some of the ways trauma can manifest in daily life.
Therapist coached patient through utilizing problem-solving skills in stressful situations.
The clinician assisted the patient to identify specific words that their families have consistently used when referring to the
client that activate (name symptoms) and, as patient reported in their own words, have caused them harm as evidenced by
(name actions taken due to the perceived harm, or name the thought process that has stayed due to the harm). The
clinician provided empathic listening to continue to foster feelings of being understood and supported. The clients feelings
of support will be beneficial in their therapeutic progress as it will strengthen the therapeutic alliance.
I usually try to go through all the symptoms one by one in this case to explore their presence. I also ask them if they can
identify reasons why they think their symptoms have improved or explore this with them. Then I write things like “client
reports significantly improved anxiety over the past week, however client attributes this to being on vacation. Will
continue to monitor symptoms”.
“Client making good progress toward tx plan goals, reports a reduction in...” then refer back to treatment plan and goals
for treatment.
Client has made progress towards their Goal of...... by indicating they haven’t experienced any symptoms related to.....
client denied having any episodes related to... etc. (that’s what I would write)
Clinician and client reviewed things they have used within the previous week. Client indicate they would like to continue
working towards ....
provided reflective listening/validation, facilitated an exploration of, assisted client in processing, etc. Looking for ways to
spice my notes up.
Therapist validated clients experience and highlighted themes of X to address tx goal of Y
Client spent much of session expressing concerns and exploring various challenges related to their daily life. Client
appeared somewhat resistant towards redirection but was provided with affirmations on positive choices that supported
their mental well-being.
Posed open-ended questions to facilitate reciprocal communication
Provided space for client to process emotions
Explored thoughts, emotions, coping skills, and barriers. Pt processed about X. X Psycho education provided. Pt
receptive.
Gains: increased insight, reduction of X as evidenced by
Client identified psychosocial barriers and processed anxiety/anger (etc) related to _____. Client engaged with SW to
identify interventional strategy (-gies) to address _____.
Allowed silence for client to guide the session through open communication that best supported treatment goals
Therapist and client discussed and processed feelings about his/her current situation. (Then add interventions if notes
require. Usually it's confronting faulty thinking, unconditional positive regard, validating....etc
Anxiety and coping
The client was asked about the frequency, intensity, duration, and history of their
anxiety symptoms, fear, and avoidance.
Consistent eye contact, active listening, unconditional positive regard, and warm
acceptance were used to help build trust with the client.
The client has continued to experience difficulty being open and direct about their
expression of painful feelings; they were encouraged to use the safe space of therapy
to express these difficult issues.
The client’s level of insight toward the presenting problems was assessed.
The client was assessed regarding the syntonic versus dystonic nature of their insight about the presenting
problems.
Therapist assessed for age-related/gender related/culture related issues that could help to better understand
their clinical presentation.
Therapist provided education about how anxious fears are maintained by a cycle of fear and avoidance that
precludes positive, corrective experiences with the feared object or situation. The client was taught about how
treatment breaks the anxiety cycle by encouraging positive, corrective experiences.
The client was taught relaxation skills such as progressive muscle relaxation, guided imagery, and regulated
breathing. Therapist assisted client in exploring differences between relaxation and tension, using guided
relaxation technique to demonstrate effectiveness in managing symptoms.
Coping skills: gratitude journal, writing journal, breathing, 5-4-3-2-1, grounding with object, running hands
under cold water, hold ice cube,
Therapist provided education on anxiety as a feedback loop and facilitated dialog using examples of scaffolding
skills to manage anxiety and challenge negative thoughts.
The client was taught to implement “worry time”—delaying the worry about various
environmental settings until a designated time. The client was taught how to recognize, stop, and postpone
worry until the agreed upon worry time. (change wording for thought stopping/radical acceptance)
EFT & Sytems
Therapist used empathic conjecture and evocative questions to assist patient in minimizing blame/criticism and
processing primary emotions including (fear of rejection, abandonment, and devaluing)
Therapist assisted patient in exploring reactions from the withdrawer position, normalizing and validating protective
stance around sharing emotion and her need to
Therapist provided education on anxious and avoidant attachment styles, normalizing and assisting couple in
acknowledging the underlying attachment needs for each partner.
Using examples of conflict during the past week, therapist assisted the couple in tracking their present process and
recognizing the presence of underlying primary emotions. Therapist provided education on primary and secondary
emotions, negative interaction cycle, and the use of anger as a function in communication.
Therapist worked with each partner, mirroring and reflecting process of exploring interpretations of communication,
reframing to assist the other partner in understanding and tracking.
Therapist and patient explored current reaction pattern of anger and self-criticism with overt hostility versus speaking
from vulnerability.
Therapist assisted patient in recognizing pattern of filtering and forecasting, challenging with possibility/positivity
statements.
Therapist reviewed Nurtured Heart approach, providing education on the three main principles: 1. Refusing to be drawn
into energizing negativity; 2. Nurturing success; 3. Clarifying expectations and boundaries. Therapist provided education
on behavior as a communication, using empathy and validation to acknowledge the positive efforts of both parents.
Themes of session:
Exploration of family life / interpersonal relationship / parent relationship / conflict with ___ / relational concerns and
issues in the workplace
Expression of emotions / thoughts / stressors
Emphasis on evaluation and exploration of problematic automatic thoughts
targeting more effective problem solving and coping skills in daily life
Emphasis on addressing problematic core beliefs
Use of role play to help address interpersonal difficulties
Use of imagery to address fears and anxieties
Exploration of filtering / forecasting / black or white thinking / exaggeration / catastrophizing / mind reading
Challenging negative statements
Reviewing coping skills