Note Outline

I: Master’s Intern/Clinician utilized (Theory Used) to support the client/youth working on [Goal

- May be helpful in putting V and Z code if Applicable] by using (name technique/intervention).

R: The sessions focus was on (introduction of Intervention/processing of behavior/ symptom/

life stressor). During the session the client/youth was partially, fully, not engaged in session

(evidenced by objective clinical observation). The Client/youth showed mild, moderate,

significant insight into the behavior/symptom/life stressor) evidenced by objective clinical

observation). The client’s noted takeaway from session was (Statement from the client). The

client stated it was helpful when (using processing/utilizing intervention/worksheet, etc.)

because it supported/helped with (Enter client statement).

P: Master’s intern/ Clinician assigned/did not assign therapeutic homework (Enter homework

expectation). Next session master’s Intern/Clinician will support the client in processing and

engaging in reflection and next steps for clients.

Collaborative Documentation Recommendations

I: Master’s Intern/Clinician utilized (Theory Used) to support the client/youth working on (Goal)

by using (name technique/intervention) in working towards (Treatment Goal)

R:

1. The sessions focus was on (introduction of Intervention/processing of

behavior/symptom/life stressor).

A. Ask client “What did we focus on today”

2. During the session the client/youth was partially, fully, not engaged in session

(evidenced by objective clinical observation).

3. The Client/youth showed mild, moderate, significant insight into the

behavior/symptom/life stressor) evidenced by objective clinical observation).

4. The client’s noted takeaway from session was (Statement from the client).

A. What is a takeaway from today?

5. The client stated it was helpful when (using processing/utilizing intervention/worksheet,

etc.) because it supported/helped with (Enter client statement).

A. What was helpful today?

 B. What was not helpful?

P:

1. Master’s Intern/Clinician and the client will meet on (Enter Date).

A. What time would you like to meet next week? Or “Does the same time work next

week”

2. Master’s intern/ Clinician assigned/did not assign therapeutic homework (Enter

homework expectation).

A. Re-explain to the client what you would like them to do (Try to make it specific –

what day could you do this, what might it look like?)

3. Next session master’s Intern/Clinician will support the client in processing and

engaging in reflection and next steps for clients.

A. What would you like to work on next time?

B. Next time I would like to talk about…….