Session Info

CPT / E&M code:

Session duration (min):

Modality:

In-person

Telehealth

Phone

Attendance:

Client

Parent / Guardian

Collateral

DBT Target Hierarchy

Target addressed:

Life-threatening behavior

Therapy-interfering behavior

Quality-of-life-interfering behavior

Skills generalization

Specific target behavior:

Diary Card Summary

Peak urge (0–5):

Actions taken:

Self-harm

Substance use

Binge / Purge

Aggression

None reported

Skills used:

Mindfulness

Distress Tolerance (TIPP, ACCEPTS, etc.)

Emotion Regulation (opposite action, check the facts)

Interpersonal Effectiveness (DEAR MAN, GIVE, FAST)

Homework completion:

Fully completed

Partially completed

Not attempted

Chain Analysis

Prompting event:

Vulnerabilities:

Links (thoughts / feelings / actions):

Consequences:

Solution / Replacement chain:

Commitment strategy:

Intervention

Interventions delivered:

Chain analysis

Solution analysis

Validation

Commitment strategies

Skills coaching / Practice

Exposure

Behavioral rehearsal

Contingency management

Risk / Safety Review

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Safety plan reviewed / updated

DBT Skills Used

Mindfulness

Distress tolerance (TIPP, self-soothe, ACCEPTS)

Emotion regulation (opposite action, PLEASE)

Interpersonal effectiveness (DEAR MAN, GIVE, FAST)

Radical acceptance

Wise mind

Plan

Between-session coaching plan:

Skills to practice:

Next session focus:

Follow-up:

Plan and Follow-Up

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

Session Info

DBT Target Hierarchy

Diary Card Summary

Chain Analysis

Intervention

Risk / Safety Review

C-SSRS

Suicidal Ideation Severity ⓘ

Suicidal behavior (lifetime; most recent date below)

Risk Details

DBT Skills Used

Plan

Plan and Follow-Up

Counseling - DBT Session Note

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