Blog
How to Document Animal-Assisted Therapy and Equine-Assisted Psychotherapy Sessions
A practical guide for therapists and counselors using animal-assisted interventions. Covers documentation requirements for AAT, AAA, and EAP, including how to connect animal interactions to clinical treatment goals and demonstrate medical necessity for insurance.
How to Document Animal-Assisted Therapy and Equine-Facilitated Psychotherapy Sessions
A practical guide for therapists who incorporate animals into psychotherapy. Covers therapeutic rationale documentation, client-animal interaction observations, equine-facilitated psychotherapy session structure, canine-assisted interventions, SOAP and DAP note adaptation, liability documentation, and insurance requirements.
How to Document Anxiety Disorder Assessment and Treatment in Therapy
A practical documentation guide for therapists treating GAD, social anxiety, panic disorder, and specific phobias. Covers intake assessments, GAD-7 and screening tools, CBT intervention notes, exposure hierarchies, medication coordination, and treatment plan updates.
How to Document Anxiety Disorder Treatment: Progress Notes for GAD, Panic Disorder, and Social Anxiety
A practical guide for therapists on documenting anxiety disorder treatment across GAD, panic disorder, and social anxiety. Covers GAD-7 and PHQ-9 score tracking, exposure hierarchy documentation, panic attack logs, safety behavior reduction, medication coordination, functional impairment, treatment goals that demonstrate medical necessity, and common documentation mistakes.
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 Attachment-Based and Relational Psychotherapy Sessions
Attachment-based and relational psychotherapy sessions involve dynamics that standard progress note formats were not designed to capture. This guide covers how to document rupture-repair sequences, track attachment pattern shifts, note countertransference observations, and write notes that reflect clinical reasoning without flattening the relational work into a behavioral checklist.
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 Behavioral Parent Training and Caregiver Coaching Sessions
A comprehensive guide for child and family therapists on documenting parent training interventions including PCIT, PMT, Triple P, and caregiver coaching. Covers note structure, skill acquisition tracking, and common documentation mistakes.
How to Document Bipolar Disorder Treatment and Mood Episode Tracking
A practical guide for therapists and prescribers on documenting bipolar disorder treatment sessions. Covers mood episode tracking, mixed states, rapid cycling, safety assessment during mania, psychoeducation, and collaborative care documentation across bipolar I, II, and cyclothymia.
How to Document Body Dysmorphic Disorder (BDD) Assessment and Treatment
A comprehensive guide for therapists treating BDD on documenting BDD-YBOCS assessments, appearance-related beliefs, mirror exposure and ritual prevention, cognitive restructuring, body checking and avoidance behaviors, dermatological procedure-seeking, and progress measurement with validated BDD instruments.
How to Document Borderline Personality Disorder Treatment: Progress Notes for DBT, Schema Therapy, and MBT
A clinical documentation guide for therapists treating BPD. Covers diagnostic assessment and differential diagnosis, DBT diary card documentation, behavioral chain analysis, crisis and safety planning for chronic suicidality, therapeutic alliance rupture-repair cycles, schema therapy mode tracking, MBT mentalizing stance documentation, medication coordination, functional impairment, and common documentation mistakes.