Blog
How to Document Recreational Therapy and Therapeutic Recreation Sessions
A practical documentation guide for Certified Therapeutic Recreation Specialists (CTRS) covering leisure assessments, functional outcome tracking, activity analysis, group recreational therapy notes, and how to connect RT goals to the broader treatment plan.
How to Document Refugee and Immigrant Mental Health Services and Cultural Assessments
A practical guide for clinicians working with refugee and immigrant populations on documenting cultural formulation interviews, interpreter-mediated sessions, trauma histories for asylum-seeking clients, acculturation stress, immigration court evaluations, and the ethical considerations around records that could be subpoenaed in immigration proceedings.
How to Document Rehabilitation Counseling and Disability Services
A practical guide for rehabilitation counselors, vocational specialists, and disability services professionals on documenting IPEs, vocational assessments, functional capacity, VR progress notes, accommodation requests, and ADA compliance records.
How to Document Sandtray Therapy Sessions
A practical guide for therapists who use sandtray and sandplay therapy on how to document sessions properly. Covers scene descriptions, miniature tracking, symbolic themes, Jungian sandplay vs directive approaches, medical necessity language, and progress notes that capture nonverbal expressive work.
How to Document Schema Therapy Sessions
A practical guide for therapists documenting schema therapy sessions. Learn how to track early maladaptive schemas, document mode cycles and limited reparenting, record experiential techniques like chair work and imagery rescripting, and write notes that satisfy insurance reviewers.
How to Document Sensorimotor Psychotherapy Sessions
A practical documentation guide for therapists trained in Sensorimotor Psychotherapy. Covers somatic observations, window of tolerance work, body-based experiments, phase-oriented trauma treatment, and how to adapt SOAP and DAP formats for bottom-up processing interventions.
How to Document Solution-Focused Brief Therapy (SFBT) Sessions
A comprehensive guide for therapists on documenting Solution-Focused Brief Therapy sessions. Covers the miracle question, scaling questions, exception-finding, compliments, and task assignments in SOAP and DAP formats that satisfy insurance reviewers without distorting SFBT's strengths-based approach.
How to Document Solution-Focused Brief Therapy (SFBT) Sessions
A practical guide for therapists using SFBT covering miracle question documentation, scaling question tracking, exception-finding, coping questions, best hopes documentation, client-generated treatment goals, and how SFBT progress notes differ from problem-focused formats like SOAP.
How to Document Somatic Experiencing and Body-Based Therapy Sessions
A comprehensive guide for somatic experiencing practitioners and body-based therapists on documenting sessions where the primary clinical data is physiological. Covers nervous system state tracking, titration and pendulation, activation and discharge cycles, and how to adapt SOAP and DAP formats for somatic work.
How to Document Somatic Symptom Disorder and Medically Unexplained Symptoms in Therapy
A practical guide for therapists documenting treatment of somatic symptom disorder (SSD), illness anxiety disorder, and functional symptoms. Covers psychological formulation, trauma-informed language, functional outcome tracking, medical provider coordination, CBT and ACT intervention documentation, insurance justification, and distinguishing SSD from malingering.
How to Document Sports Psychology and Athletic Mental Performance Sessions
A practical guide for sports psychologists and performance consultants on documenting mental skills training, performance anxiety treatment, injury recovery counseling, and return-to-play psychological clearance. Covers non-clinical vs clinical documentation distinctions, team consultation reports, and NCAA mental health mandate implications.
How to Document Structural Family Therapy Sessions
A practical guide to documenting structural family therapy sessions. Learn how to record family structure maps, subsystems, boundaries, hierarchies, enactments, and restructuring interventions without losing the systemic perspective that makes SFT documentation clinically meaningful.