Marriage and Family Therapy Session Note (DAP)

Date of Service: [Date]   Start–Stop Time: [HH:MM–HH:MM / total minutes]   Provider: [Name, credentials]   Modality: [in-person / video / audio-only]   Session Type: [individual / couple / family / collateral]   Participants: [Full names with roles/relationships, identify the primary client] (If any participant attended only part of the session, note entry/exit times.)   Focus: [Chief focus for session]   Diagnosis Addressed: [ICD-10 code and label / Per treatment plan]

(If telehealth: confirm informed consent obtained and document patient location/state.)

Data

[Interval history and session focus narrative] (3–6 sentences covering symptom changes, relational/family events, homework adherence, and stressors since last session. Attribute information to source if not from the identified client—e.g., "Partner reports…" Use direct quotes sparingly and only for safety-critical statements.)

• Observations: [Clinically relevant presentation and relational dynamics] (Appearance, mood/affect, and high-level interactional patterns. Include MSE findings only if abnormal.)
• Interventions: [Interventions delivered with brief rationale tied to treatment goals] (List each intervention and its connection to goals. Add bullets as needed.)
• Response: [Each participant's engagement and response to interventions] (Note observable shifts in dyadic/family interaction, barriers encountered, or skills practiced.)
• Risk Update: [SI/SH status: denied / endorsed] — [HI/violence risk: denied / endorsed] — [Abuse/neglect concerns: none / suspected / reported] — [Level of care: appropriate for outpatient / higher level indicated] (If any risk endorsed, document ideation, plan, intent, protective factors, means access, and actions taken. Include crisis resources provided if applicable. If not assessed, state reason and follow-up plan.)

Assessment

[Clinical synthesis of current individual and relational/systemic status] (Differentiate observations from inferences. Describe relevant patterns such as pursue–withdraw, triangulation, or problem-maintaining cycles.)

• Progress toward goals: [Goal]: [improving / stable / worsening] — [Behavioral/functional evidence]. (Repeat for each goal addressed. If no progress, note barriers and planned approach changes.)
• Risk formulation: [Overall risk level: low / moderate / high] — [Brief justification and protective factors] (Include mitigation steps if risk above baseline.)
• Medical necessity: [Statement linking today's interventions to the diagnosed condition and functional impairment being addressed]

Plan

• Next session: [Planned focus] — [Expected participants] — [Modality if changing]
• Homework: [Between-session tasks] (or "None assigned")
• Referrals/coordination: [Referrals, collateral contacts, ROI status] (Omit if none.)
• Safety plan: [Reviewed / Updated / N/A] (Include key elements and crisis resources if risk above baseline.)
• Treatment plan updates: [Changes made / No changes]
• Follow-up: [Next appointment date/time or "to be scheduled"] — [Frequency]

(For time, participants, and risk: if not obtained, document "Not assessed—[reason]" with plan to assess at next contact.)