Session Documentation

Date, modality, attendance, CPT, participants, presenting concerns, interventions, and client response.

Mood / SI / HI:

Plan and Follow-Up

Focus	Documentation
Assessment	Clinical impression, response to interventions, progress toward goals, risk, and medical necessity. Clinical impression: Progress / response: Risk status:
Interventions	Document interventions delivered, skills practiced, education, coordination, and patient engagement. Interventions today: Patient response: Coordination / education:
Plan	Next focus, homework or protocol changes, referrals/orders, monitoring, and appointment cadence. Next steps: Home practice / instructions: Follow-up:

Focus

Documentation

Assessment

Clinical impression, response to interventions, progress toward goals, risk, and medical necessity.

Clinical impression:

Progress / response:

Risk status:

Interventions

Document interventions delivered, skills practiced, education, coordination, and patient engagement.

Interventions today:

Patient response:

Coordination / education:

Plan

Next focus, homework or protocol changes, referrals/orders, monitoring, and appointment cadence.

Next steps:

Home practice / instructions:

Follow-up: