Equine-Assisted Psychotherapy Session Note (DAP)

Date of Service: [Date]

Patient: [Patient name or ID]

Clinician: [Name, credentials]

Session Duration: [Start–Stop times / Total psychotherapy minutes]

Service Type: [Individual / Family / Group]

Modality: [in-person / telehealth / hybrid]

Location: [Location/site]

Equine Participation: [Yes / No] (If Yes, specify horse name/ID and [ground-based / mounted].)

Equine Specialist/Handler: [Name, if applicable]

Treatment Goals Addressed: [Treatment goals addressed this session]

Diagnosis: [Primary diagnosis; additional diagnoses as applicable]

Data

[Session focus and interval update] (State reason for today's session; summarize changes since last contact such as sleep, mood, stressors, relationships, and functioning; identify the primary therapeutic target for today. Describe events and observations without clinical interpretation.)

[Patient presentation and mental status observations] (Document appearance, behavior, speech, affect and any shifts during session, and engagement level. Include key patient statements using brief direct quotes only when clinically meaningful. Avoid interpretation.)

[Equine-assisted interventions and interactions] (Describe equine-related activities performed—e.g., grooming, leading, liberty work, boundary exercises. Delineate team roles: what the therapist did vs. the equine specialist/handler. Use concrete behavioral terms to describe horse–client interaction sequences—approach/avoidance, distance changes, startle responses, client regulation attempts—without attributing internal states to the horse. Include psychotherapy techniques delivered during equine work and note the patient's observable responses. Omit this paragraph entirely if no equine contact occurred.)

[Risk and safety update] (Document suicidal and homicidal ideation status, self-harm, and any safety concerns. If risk factors are present, include intent, plan, access to means, and protective factors. If not formally assessed, state the reason and plan to address. Note any physical safety incidents during the session—falls, near-misses—with immediate response and disposition.)

Assessment

[Clinical impression] (Synthesize what today's presentation indicates about current symptom status and functioning. Describe how equine-assisted work contributed to the clinical process—e.g., in-vivo affect regulation practice, relational pattern awareness, experiential exposure to interpersonal triggers. Include a brief medical necessity statement when needed for billing, identifying the symptom/impairment requiring psychotherapy and why equine-assisted modality was clinically appropriate.)

[Progress toward treatment plan goals] (For each goal addressed, note the objective/indicator, progress status [improved / stable / regressed], and key barriers or supports. Keep concise.)

[Risk determination] (Include only if any risk factor was present or changed. State overall risk level [low / moderate / high], whether it changed from baseline, the rationale anchored to session data, and mitigation steps taken—e.g., safety plan update, means counseling, level-of-care discussion. Omit if risk screen was negative and unchanged.)

Plan

[Next session plan and between-session assignments] (Identify next therapeutic targets; outline planned equine activities and their clinical purpose; note any modifications needed. Specify homework tied to session learning—skill practice, journaling—with expected frequency.)

[Safety and coordination actions] (Include only if risk concerns or care coordination are needed. Document safety plan status, crisis contacts provided, follow-up interval adjustments, collateral contacts, and any referrals initiated.)

Next Appointment: [Date/time or TBD]

Clinician Signature: [Name, credentials, date/time signed]