Conjoint Family/Couples Psychotherapy Progress Note

(Use neutral, concise clinical language. Omit any section header with no applicable content, except Safety—include at minimum a brief attestation each session. Do not auto-populate negative findings; if not assessed, state "not assessed this session" with reason. Attribute perspectives and observations to specific participants. Brief direct quotes may be used only for high-stakes safety content.)

Date: [date of service]

Time: [start time] – [end time] ([total psychotherapy minutes] min)

Modality: [in-person / telehealth video / telehealth audio]

Clinician: [name, credentials]

Participants:

• [Identified patient: name or role, relationship to other attendee(s)] (Designate clearly for billing)
• [Attendee: name or role, relationship to identified patient] (Note if present for only part of session or if breakout occurred)

CPT: [90846 / 90847] (90846 if identified patient not present; 90847 if identified patient present)

Session Focus & Interval History

[Reason for today's session, key relational events or symptom changes since last visit, adherence to prior homework/plan] (2–4 sentences. When participants report conflicting accounts, attribute each perspective to the specific speaker.)

Observations

(Clinician-observed behaviors; keep behaviorally anchored and attribute to specific participants. Label interpretations as clinical impressions.)

• [Engagement and affect by participant]
• [Interactional patterns observed] (e.g., escalation, withdrawal, repair attempts; specify who initiates/responds)
• [Other notable behavioral observations relevant to clinical status]

Assessment & Relational Formulation

[Clinical status of identified patient relative to diagnosis and treatment goals] [Relational formulation: maintaining cycle/pattern, key triggers, and strengths/protective factors] (Include brief statement linking conjoint work to the identified patient's treatment needs to support medical necessity.)

Interventions

• [Intervention → target] (Format: technique or activity → specific cycle, skill, or symptom addressed)
• [Measures or tools administered, if any]

Safety

Risk: [Assessed / Not assessed this session] (If assessed: suicidal ideation, self-harm, violence risk; state risk level, brief rationale, and any safety actions. If not assessed, state reason.)

IPV Screening: [Screened privately / Not screened] (Include when clinically indicated: relationship conflict, observed fear, pregnancy/postpartum, trauma history, or per protocol. Document result and any safety actions/referrals. If conjoint format contraindicated, document rationale and adjusted plan.)

(If no acute concerns, a single-line attestation is sufficient: "Risk assessed; no acute safety concerns identified.")

Plan

• Next session: [date/interval, focus, format]
• Home practice: [specific assignment with who does what]
• Coordination/referrals: [if applicable]
• Contingency: [what to do if conflict escalates or symptoms worsen]

Clinician Signature: [signature, credentials, date/time]