Session Info

CPT code:

Session duration (min):

Modality:

In-person

Telehealth

Phone

Attendance:

Client

Parent / Guardian

Collateral

Interpreter

DATA

Session themes / Client report:

Key client statements:

Interventions delivered:

CBT — cognitive restructuring

DBT skills training

Psychoeducation

Motivational interviewing

Supportive therapy

Exposure / Behavioral activation

EMDR processing

Crisis intervention

Client engagement:

Actively engaged

Somewhat engaged

Resistant / Guarded

Distracted / Disengaged

ASSESSMENT

Diagnosis Search

Working diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Progress toward goals:

Significant progress

Moderate progress

Minimal progress

No change

Regression

Risk status:

No current risk

Low risk

Moderate risk — safety plan reviewed

High risk — see safety documentation

Clinical impression:

PLAN

Next session focus:

Homework / Practice:

Follow-up:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Counseling - DAP Progress Note

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