Group Session Note (Animal-Assisted Therapy)

GROUP-LEVEL CONTENT

Date of Service: [Date of service]

Start Time / End Time: [Start time] / [End time]

Total Duration: [Total duration in minutes]

Location/Setting: [Location or setting]

Group Name/Type: [Group name and type]

Facilitator(s): [Facilitator name(s) and credentials]

Therapy Animal Team: [Species, animal name, handler name, and credentialing status as applicable]

Group Size: [Number of participants]

Consent/Screening: [Group confidentiality review and AAT consent/screening status] (Affirm confidentiality reviewed; note any new AAT consents, contraindication screens, or animal welfare checks. Use "previously reviewed, no changes" if policy allows.)

Session Content

Objectives: [Session objectives linked to standing group goals]

Interventions & AAT Activities: [Clinical interventions and AAT activities used] (Name specific therapeutic modalities and animal-assisted tasks such as grounding, boundary coaching, graded interaction, psychoeducation, or skills practice.)

Session Structure: [General session flow] (Briefly outline opening, core activities, and closing/processing.)

Engagement & Dynamics: [Overall group engagement and dynamics] (Describe collective participation without identifying specific members; use neutral phrasing such as "a group member.")

Safety/Incidents: [Safety incidents and actions taken] (Only include if an incident occurred. Document what happened, actions taken, animal welfare response, and whether incident report was completed. Omit this field if no incidents.)

PATIENT-SPECIFIC CONTENT

Participation & Presentation

Attendance: [present / absent] (If partial attendance: note time in/out and reason if known.)

Participation Level: [none / minimal / moderate / active / leadership]

[Patient-specific summary of participation and presentation] (Describe what the patient did during the session: contributions, response to prompts, engagement quality. Include relevant subjective statements from the patient and objective observations such as affect, behavior, attention, and interaction with staff/animal. For behavioral health contexts, include brief mental status observations as relevant; for rehab-focused groups, emphasize functional participation. Do not include identifying details about other group members.)

Response to Animal Interaction

Interaction Type: [direct contact / proximity only / observation only / refused / not offered due to contraindication]

[Patient-animal interaction and response] (Describe what the patient did with the animal: approximate duration, tasks attempted, boundaries observed, hygiene adherence. Document emotional, physiologic, or behavioral response such as calming effect, increased engagement, anxiety, or avoidance. Note any safety concerns, boundary coaching provided, and effectiveness of redirection. If AAT was not delivered, state: "AAT not delivered today: [reason].")

Assessment

[Clinical interpretation relative to individualized treatment goals] (Summarize how today's participation and AAT response relate to the patient's goals. Note change from prior session: [improved / unchanged / worsened] with supporting behavioral observations. Include medical necessity rationale when relevant.)

Plan

[Individualized takeaway, coping tool, or between-session practice if assigned]

[Next session focus or modifications to AAT approach]

[Coordination, referrals, or risk plan update] (Only include if clinically indicated.)

(Documentation integrity: Each patient note must contain at least one patient-unique observation and one patient-unique assessment or plan element. Do not clone text across patients. If session time, group size, or consent/screening status is unknown, keep the field present but incomplete rather than estimating.)