CBT first treatment session notes example
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Authors:
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Angela
Jones and Jen Clue (Senior CBT Therapists)
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Date:
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20/08/2025
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Data
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Treatment Session Notes
Patient First Name: James
Patients Last Name: Smith
Date of Session: 22/05/2024
Session Number: 1
Treating Clinician: A
Therapist
Treatment Type: CBT
Treatment Modality: CBT
If cCBT please enter Silvercloud ID: ID number or N/A
Current Pathway: In Treatment
Current Work Status: Full
duties
Primary Working Diagnosis/Primary
Presentation: Depression
Agenda/Session
focus:
· Contracting
· MDS review
· Risk review
· Assessment
· Goals
· Set home
task
· Feedback on
session
Problem
Statement/Formulation details:
Reports a steady decline in
mood over the past few years. Struggles
with thoughts of losing his job and easily becoming stressed over daily
tasks. Significant levels of self-critical
thinking linked with various difficult life experiences.
Goals:
To focus on being more optimistic and to reduce negative thinking – by
capturing the positive aspects of his day, not just the problems being faced.
To reduce rumination and self-critical thinking and to be more positive about
the future.
Beckian longitudinal
formulation to be completed.
Review
In-between session:
Today is the first sessions
thus there are no previous home tasks to review.
Content of
Session:
Contracting: We discussed
the number of sessions (12 x 1-hour sessions), confidentiality (and when it
would be broken), we recapped the cancellation/DNA protocol and James was in
agreeance with all the above. We also spoke about the importance of engaging in
therapy sessions and home tasks.
MDS review: James’s scores
on the PHQ9 and GAD7 are reported to be an accurate reflection of his current
symptoms.
Assessment:
Onset: James reported a
1-year history of work-related stress which is exacerbating his symptoms of low
mood. James said that he has lost his work/life balance and feels that he is
failing.
Physical symptoms: tension,
lethargy, poor sleep and motivation.
Behaviours: James reported
that he has withdrawn from his usual social activities (such as playing
football with peers), he is spending a lot of time at home away from his family
(i.e., working in the study as opposed to socialising in family areas), James
also reported that he “overworks” and spends a lot of his time on his work
laptop.
Cognitions: “I am going to
get sacked”, “I am not good enough”, “Why did they even hire me?”, “I am
letting myself and my family down”.
Emotions: low, stressed,
hopeless, worried.
Impact: James does not feel
that he is ‘giving his all’ at work, he is also withdrawing socially (see
above) and feel that he is not as ‘present’ at home with his wife and
family.
Psychotropic medication:
none reported.
Past treatment: James has
not had any treatment historically.
Past psychiatric diagnoses:
none reported.
In session I introduced the
CBT model, and we explored how CBT could support James in reaching his goals.
Agreed between session task:
James to read information
sent on CBT.
Treatment Plan:
Beck cognitive model of
depression.
We will commence using a 5
areas model to inform this formulation further.
Session
feedback and Learnings:
James reported feeling “some
hope” after learning about CBT in today’s session.
Risk Assessment
Please
do not use N/A. Please indicate that you have explored this with your client
and document their response.
Suicidal
Thoughts:
James scored 0 on PHQ9 Q9.
We discussed this further, and James confirmed that he had no suicidal or
self-harm thoughts, and he felt able to keep himself safe.
Current Plan:
James confirmed he had no
plans to harm himself or end his life.
Access to Means:
James confirmed that he had
not made any preparations or gathered any means by which to harm himself or end
his life.
Intent Rating:
0/10
Self-harm
Thoughts:
James confirmed he had no
self-harm thoughts.
History:
James has disclosed one
historic suicide attempt by taking an overdose or 20 Paracetamol and 20
Ibuprofen. This was 7 years ago, and he has not made any attempts since then.
James said that he was in a difficult place at the time following several
bereavements in a short space of time. James described that once he had
taken the medication, he regretted it and called 111, he was advised to present
himself at hospital which he did. He was signposted to Cruse but did not pursue
this.
Risk Factors:
James feels that job loss or
a bad performance review at work could be a risk factor.
Alcohol: James
reported that he has stopped drinking and has not drunk alcohol for
approximately 1 year. Prior to this he reported that he would have “a couple of
beers” at the weekend with friends.
Recreational drugs:
None reported.
Smoke/vape: Jame reported
that he does not smoke or vape.
Caffeine: James reported
that he has 1 cup of tea a day. He denied any use of energy drinks
Current Triggers:
James’s triggers for
increased low mood and anxiety are all around work-based
stress.
Making mistakes/fear of
making mistakes
Performance reviews at
work
Being tired from working
long hours
Safeguarding Issues:
There are no current
safeguarding concerns based on the information James disclosed.
Protective Factors:
James confirmed that his
children and his wife are his protective factors. He wants to manage work and
his stress levels better for their sake.
Risk Management
and Safety Plan:
James has confirmed if
anything was to change, he would reach out to his GP, or NHS 111 (if out if
hours). James has been provided with a safety plan which has been uploaded to
his file as an attachment. The safety plan also contains contact details for
services such as the Samaritans.
Risk Formulation:
James presents with one
historic suicide attempt (please see above for further details), this was
triggered by several bereavements in a short space of time.
Since this time (7 years
ago), James reported he has much hope for the future, especially since he has
got married and had children.
James reported not currently
experiencing any suicidal thoughts or thoughts to self-harm. He stated that he
would reach out to professional services if these thoughts were to re-occur.