Blog
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.
How to Document Brainspotting Therapy Sessions
A practical guide for Brainspotting-trained therapists on documenting BSP sessions. Covers the six-phase model, activation scale tracking, gaze point documentation, body awareness notes, Focused vs Natural Brainspotting differences, resource model documentation, neurobiological processing notes, billing, and common documentation mistakes.
How to Document CBT for Insomnia (CBT-I) Sessions
A practical guide for therapists delivering Cognitive Behavioral Therapy for Insomnia. Covers sleep diary data integration, stimulus control and sleep restriction parameter tracking, sleep efficiency calculation, the multi-session protocol structure, hypnotic taper coordination, validated outcome measures like the ISI and PSQI, and documentation for comorbid presentations.
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 Collaborative Assessment and Management of Suicidality (CAMS) Sessions
A practical guide for therapists using the CAMS framework on documenting the Suicide Status Form, initial and tracking sessions, treatment plan drivers, and CAMS resolution. Covers required SSF fields, common documentation mistakes, and how structured templates support fidelity.
How to Document College Counseling Center Sessions and Brief Therapy Models
A practical guide for college and university counseling center clinicians on documenting therapy sessions within the unique constraints of higher education settings. Covers FERPA vs HIPAA distinctions, brief therapy documentation, triage assessments, crisis notes, group therapy, and discharge documentation for high-volume caseloads.
How to Document Compassion-Focused Therapy (CFT) Sessions
A practical guide for therapists on documenting Compassion-Focused Therapy sessions: covering the three emotion regulation systems, compassionate mind training, fears and blocks to compassion, SOAP and DAP note formats, and how to track CFT-specific progress goals.
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.