Family Psychotherapy Session Note (Identified Patient Not Present)

Date of Service: [Date of service]

Service Type: Family psychotherapy / caregiver-only, identified patient not present

Identified Patient: [Patient full name and identifiers]

Clinician: [Clinician name and credentials]

Participants Present: [Each participant's name and relationship to patient]

Setting: [in-person / telehealth] (For telehealth, include modality and caregiver location.)

Session Time: [Start time]–[Stop time] ([Total minutes] minutes)

Session Context

Patient Presence: Identified patient was not present.

Reason for Absence: [Reason for absence] (State if planned caregiver session per treatment plan, patient decline, logistical barriers, or clinical rationale for caregiver-only work. If unknown, state "Not assessed.")

Medical Necessity: [Medical necessity statement linking caregiver/family interventions to the patient's diagnosis and treatment targets] (State why caregiver-focused intervention is expected to improve or maintain the patient's functioning.)

Consent Status: [Consent status for caregiver involvement] (For minors, identify legal guardian. For adults, confirm patient consent or document clinical basis. Note if confidentiality ground rules were reviewed. If not addressed, state "Not assessed.")

Caregiver Report

(Attribute sources clearly: caregiver observed vs. patient reported to caregiver vs. caregiver assumption.)

Interval Update: [Caregiver-reported changes in patient symptoms, behaviors, and functioning since last contact, tied to treatment targets] (If no updates available, state "No interval change reported" or "Caregiver unable to provide details.")

Treatment Adherence: [Medication adherence, therapy homework, skill utilization as reported]

Caregiver Priorities: [What the caregiver wants help with this session]

Strengths/Protective Factors: [Family/patient strengths, supports, effective strategies]

Clinical Observations

Caregiver Presentation: [Engagement, affect, insight, capacity to learn and implement skills]

Family Interaction: [Communication patterns, alignment, conflict observed during session]

Limitations: Identified patient not present; patient appearance and behavior not directly observed.

Interventions & Response

(Document each intervention with specificity. Avoid vague labels like "supportive psychotherapy provided.")

Interventions Provided: [Intervention type and specific content: skills taught, scripts practiced, plans created, psychoeducation delivered] (Link each intervention to the patient's treatment goals.)

Caregiver Response: [Understanding demonstrated, skill acquisition, barriers identified, readiness to implement]

Progress Toward Patient Goals: [improved / stable / worsened / mixed] (Clinical impression based on collateral report.)

Risk/Safety Assessment: [No safety concerns endorsed by caregiver] (If concerns present, document what was reported, actions taken, and follow-up plan. If not assessed, state "Not assessed.")

Plan

Caregiver Homework: [Specific actions, frequency, and tracking method]

Patient Engagement Plan: [Whether next session will include patient; steps to involve patient if indicated]

Referrals/Resources: [Resources provided, care coordination] (Include only if applicable.)

Next Appointment: [Timeframe/date and modality]

Clinician Signature: [Typed name, credentials]

Date Signed: [Date]

Supervisory Attestation: [Supervisor name, credentials, and attestation statement] (Include only if applicable.)