Session Info

CPT / E&M code:

Session duration (min):

Modality:

In-person

Telehealth

Attendance:

Client

Parent / Guardian

Collateral

EMDR Phase

Phase(s) addressed today:

Phase 1 — History & Treatment Planning

Phase 2 — Preparation (safe place, resources)

Phase 3 — Assessment (target, NC, PC, SUD, VOC)

Phase 4 — Desensitization (BLS sets)

Phase 5 — Installation (PC strengthening)

Phase 6 — Body Scan

Phase 7 — Closure

Phase 8 — Reevaluation

Target Setup

Target memory / Image:

Negative cognition (NC):

Positive cognition (PC):

Emotions:

Body sensation / Location:

Outcome Tracking

SUD start (0–10):

SUD end (0–10):

VOC start (1–7):

VOC end (1–7):

Processing

BLS sets completed:

Changes noticed (imagery / cognition / affect / somatic):

Blocking beliefs / Cognitive interweaves:

Feeder memories identified:

Closure

Body scan result:

Clear — no residual disturbance

Residual sensation — location:

Closure technique:

Safe place / Calm state

Container exercise

Light stream

Grounding / Breathing

Client stable at end:

Yes — oriented and grounded

No — see safety documentation

Adverse Childhood Experiences (ACE)

1. Emotional abuse by parent or adult in household

Yes No

2. Physical abuse by parent or adult in household

Yes No

3. Sexual abuse

Yes No

4. Felt no one in family loved or supported you

Yes No

5. Lacked food, clothing, or protection due to neglect

Yes No

6. Parents separated or divorced

Yes No

7. Mother or stepmother treated violently

Yes No

8. Lived with someone with substance use problem

Yes No

9. Lived with someone with mental illness or attempted suicide

Yes No

10. Household member went to prison

Yes No

Safety

Dissociation screen completed or clinically ruled out

Risk / safety review completed

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

Counseling - EMDR Session Note

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