Grief Counseling Progress Note (Family Session)

Date of Service: [Date of service]

Session Time: [Start–end time or total face-to-face minutes]

Setting/Modality: [in-person / video / phone]; [Location type]

Provider: [Provider name and credentials]

Participants Present:

• [Name] — [Relationship to identified patient or decedent]; [adult / minor]; [present for all / part of session] (Mark one participant as the Identified Patient)
• (Add additional participants as needed)

Absent/Expected: [Invited but absent participants and reason if known] (Omit line if none expected)

Consent/Confidentiality: [Confirmation that informed consent is on file, confidentiality limits reviewed, and family therapy ground rules established; note interpreter use or releases if applicable] (Omit if documented elsewhere in session)

Session Focus

[Presenting concern framed as a family-centered grief issue; loss context including relationship to deceased, timeframe since death, and whether expected or sudden/traumatic; current phase of bereavement and pressing stressors] (For ongoing cases, integrate brief interval update for each participant covering grief emotions, functioning, coping, and family dynamics. Use paraphrase rather than extensive direct quotes. If loss details are unknown, state that information was not disclosed.)

Observations

[Mental status observations for identified patient and any participant with clinically relevant findings, including appearance, affect, speech, and thought content as pertinent] (If MSE was not formally assessed, note briefly with rationale.)

[Observable family interaction patterns: turn-taking, escalation or de-escalation, alliance patterns, responsiveness to repair attempts, caregiving behaviors] (Keep observations factual and behavioral; defer interpretation to Assessment.)

Assessment

[Clinical formulation integrating grief process stage, protective factors, and risk factors; indicators suggesting prolonged or complicated grief trajectory; co-occurring symptoms to monitor; relevant cultural or spiritual factors; progress toward treatment goals with supporting evidence and barriers; diagnosis or problem focus if applicable] (Include brief statement of medical necessity for family modality when billing. If diagnostic assessment is deferred, state that it is ongoing.)

Interventions

• [Intervention delivered] — [Target or goal] (Family response: [behavioral markers of engagement or change])
• [Additional intervention] — [Target or goal] (Family response: [markers])
• (Add interventions as needed; note any planned intervention not delivered with reason)

Risk & Safety

[Suicide and self-harm screening results with current ideation status, protective factors, and overall risk level; violence, abuse, or neglect concerns if assessed; safety plan status if created or updated] (If no risk concerns present, document negative screen and absence of acute safety concerns. If not assessed, state reason and mitigation steps.)

Plan

Next Session: [Date, time, modality, and expected participants]

Home Practice: [Concrete, measurable assignment for the family with specified frequency and roles]

Referrals/Coordination: [Referrals made or pending with releases noted] (Omit if none)

Treatment Plan Updates: [Goal revisions or transition planning] (Omit if unchanged)

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

Supervisor Co-signature: [Name, credentials, date/time] (Include only if required)