CBT Session Progress Note (DAP)

Date of Service: [date]

Patient: [name; MRN or DOB]

Provider: [name, credentials]

Modality: [in-person / telehealth (video / audio-only)]

Session #: [number] (Include only if tracked.)

Data

Interval update: [Patient-reported symptoms, functioning, and stressors since last session; mood/anxiety rating if obtained; changes in sleep, energy, or substance use only when clinically meaningful]

Measures: [Instrument name, score, change from prior, brief interpretation] (Include only if standardized instruments were administered. If expected but not done, state "Not administered—[reason]." Omit entirely if no measures used or expected.)

Risk screening: [SI: denied/endorsed; SH: denied/endorsed; HI: denied/endorsed] (If endorsed, include frequency, intensity, plan/intent/means, and actions taken. If not assessed when expected, state "Not assessed—[reason].")

Homework review: [Prior assignment, completion level, barriers, insights] (Omit if first CBT session. If deferred due to crisis, state explicitly.)

Agenda: [Collaboratively set session priorities]

Interventions delivered: [Specific CBT techniques used—e.g., psychoeducation (topic), cognitive restructuring (target belief), behavioral activation (activities), exposure work (targets), skills training (technique), Socratic questioning, relapse prevention—with enough detail that another clinician understands the therapeutic work; avoid generic phrases like "supportive therapy provided"]

Patient response: [Engagement level, skill demonstration, emotional response, therapy-interfering behaviors if addressed]

Brief observations: [Notable appearance, affect, thought process findings] (Include only if clinically relevant or changed from baseline; omit if stable.)

Assessment

[Clinical synthesis organized by active problem or treatment goal; for each, state status (improving/unchanged/worsening) with supporting evidence from measures, patient report, or observed behavior/skill use]

Risk level: [low / moderate / high] — [brief rationale citing key risk and protective factors; safety actions if elevated]

Medical necessity: [Concise statement linking symptom burden, functional impairment, or relapse risk to need for continued CBT; avoid circular reasoning]

Plan

Homework assigned: [Task(s), frequency, target symptom/mechanism; anticipated barriers and strategies if discussed]

Next session: [Provisional agenda topics and planned interventions]

Follow-up: [Next appointment date/time and modality, or "to be scheduled"]

Coordination: [Collateral contacts, referrals, medication management notes] (Include only if applicable.)

Safety plan: [Reviewed/updated; crisis resources provided] (Include only if risk is nontrivial.)

Telehealth Addendum

(Include only for telehealth sessions; omit entirely for in-person visits.)

Patient Location: [Address or city/state sufficient for emergency response]

Callback Number: [phone]

Emergency Contact: [Name, relationship, phone; permission to contact in crisis: yes/no]

Privacy Confirmed: [yes / no; others present if applicable]

Disconnection Plan: [reviewed / confirmed]

Time Documentation

(Include only when supporting timed psychotherapy billing; omit when not required.)

Psychotherapy Time: [Start–stop times or total minutes face-to-face with patient] (Do not estimate or include documentation time.)