CBT first treatment session notes example

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As a registered health professional, Vita Health Group will need to make treatment notes about your condition. These notes constitute a medical record, and as such we are legally obliged to store them confidentially for up to 8 years, after which they will be destroyed.

Notes are stored electronically in line with current data protection regulations and healthcare governing body guidance. The data may be used for audits and statistical analysis, but it is not possible to identify anything about you personally.

For further information on our data protection policy, please visit https://www.vitahealthgroup.co.uk/data-protection-policy/       

Consent

We may also provide reports about your condition and treatment to Healthcare Professionals involved in your care, such as your GP. Do you give your consent that I can contact your GP about these difficulties if I think it would help?: *

Yes

×

If we are concerned for your safety at any time during your treatment, this would be discussed with you and we will request your consent to contact your GP or other services. In the event that you do not consent, we may still go ahead if we feel that you are risk to yourself or someone else.

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

Current Pathway: * In Treatment

Current Work Status: * Full duties

Primary Working Diagnosis/Primary Presentation: * Depression

Agenda: *

-            Contracting

-            MDS review

-            Risk review.

-            Assessment

-            Goals.

-            Set home task.

-            Feedback on session.

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.

Goals: James said that he would like to get to a point where he has a better work/life balance and is not so worried about failing at work.

Home task: James to read information sent on CBT.

In session I introduced the CBT model, and we explored how CBT could support James in reaching his goals.

Session feedback: James reported feeling “some hope” after learning about CBT in today’s session. 

Treatment Plan:

We will commence using a 5 areas model to inform our formulation. Probable formulation on information gathered to date – Beck formulation.

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: *

James confirmed he had no thoughts and intent is low.

Self-harm Thoughts: *

James confirmed he had no self-harm thoughts since our last session.

History: *

James has disclosed one historic suicide attempt. 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. 

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 initial assessment 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.

Risk Rating: *

Low

Does this clients risk presentation require review by VHG Risk Duty?: *

No

If yes Rationale for risk review: *

N/A

Clinician Requests

Please use this section to complete any additional sessions requests or request for clinical review.

Do you need to request additional sessions: *

No

×

If yes Rationale for additional sessions: *

Request clinical review of case by VHG clinical team?: *

No

×

If yes Reason for clinical review: *