Blog
How to Document Applied Behavior Analysis (ABA) Therapy Sessions
A practical guide for BCBAs and RBTs on documenting ABA therapy sessions. Covers session note structure, data collection, behavior reduction, skill acquisition tracking, insurance requirements, and common documentation mistakes.
How to Document Art Therapy Sessions
A practical guide for art therapists and expressive therapists on documenting sessions that involve creative media. Covers what makes art therapy documentation unique, adapted note formats, ethical considerations for artwork storage and photography, and common documentation mistakes.
How to Document Autism Spectrum Evaluations and Support Plans
A practical guide for psychologists, school psychologists, and multidisciplinary teams on documenting autism spectrum evaluations. Covers ADOS-2 and ADI-R documentation, evaluation report structure, support plan writing across clinical and educational settings, cross-provider coordination, and common documentation mistakes that delay services.
How to Document Child and Adolescent Therapy Sessions
A comprehensive guide for therapists who work with minors on the unique documentation requirements of child and adolescent therapy. Covers play therapy observations, parental involvement, school coordination, mandatory reporting, and SOAP format adapted for child work.
How to Document Cognitive Behavioral Therapy Sessions
A practical guide for CBT therapists on how to document sessions effectively. Learn what to include in progress notes for CBT, how to track thought records, behavioral experiments, and exposure hierarchies, and how to demonstrate measurable progress.
How to Document Cognitive Processing Therapy (CPT) Sessions
A practical guide for therapists on documenting CPT sessions. Learn what to capture across the 12-session protocol, how to document stuck points worksheets and Socratic dialogue, what insurance reviewers need to see for trauma-focused therapy, and the documentation errors that create audit and compliance risk.
How to Document Couples and Family Therapy Sessions
A practical guide for therapists on the unique documentation challenges of couples and family therapy. Covers who the identified client is, separate vs joint records, confidentiality between partners, SOAP format for relational work, CPT codes, and common documentation mistakes.
How to Document Court-Ordered and Mandated Therapy Sessions
A practical guide for therapists documenting mandated treatment: DUI counseling, anger management, domestic violence programs, and probation-ordered therapy. Covers compliance tracking, court reports, dual reporting obligations, and managing documentation when the client's goals differ from the court's.
How to Document Crisis Intervention and Suicide Risk Assessments
A practical guide for therapists and social workers on documenting crisis interventions, suicide risk assessments, safety plans, and involuntary holds. Covers real-time capture, clinical decision-making language, what protects versus exposes clinicians legally, and the documentation errors that create liability.
How to Document Crisis Interventions in Therapy and Social Work
A comprehensive guide for therapists and social workers on documenting crisis interventions, including suicidal ideation assessments, safety plans, involuntary holds, mandated reporting, and critical incident debriefs. Covers what to include, how to write defensibly, risk management language, and timing requirements.
How to Document Dialectical Behavior Therapy (DBT) Sessions
A practical guide for DBT therapists on documenting individual therapy, skills group, diary cards, chain analysis, behavioral targets, consultation team notes, and phone coaching contacts without reducing the treatment to a checklist.
How to Document Eating Disorder Treatment Sessions
A practical guide for clinicians treating eating disorders on how to document sessions involving medical monitoring, weight tracking, meal plan coordination, body image work, level of care decisions, and multidisciplinary team communication.