Mental Health Music Therapy Session Note (Song Discussion/Lyric Analysis)

Patient: [Patient full name], MRN: [MRN], DOB: [DOB]

Date of Service: [Date]

Setting: [Inpatient / Residential / PHP / IOP / Outpatient]

Modality: [in-person / telehealth]; [individual / group]

Clinician: [Clinician name, credentials]

Session Time: Start [HH:MM], Stop [HH:MM], Total direct contact minutes: [Minutes] (Required for billing; do not leave blank.)

Group Details: Group size: [#] | Patient attendance: [full session / partial—arrived late / partial—left early / partial—stepped out] (Include only for group modality.)

Reason for Session

[Patient-stated focus or clinical reason for session] [Relevant interval changes since last contact] [Session objective(s) linked to treatment plan goals] (Write 2–4 sentences. Include interval history only if known; omit rather than speculate.)

Safety Status

• Suicide/Self-harm: SI [denied / passive / active]; Plan [denied / present]; Intent [denied / endorsed]; NSSI [denied / endorsed]. [Details if endorsed, using patient's own words when clarifying]
• Homicidal Ideation/Violence Risk: HI [denied / passive / active]; Plan/Intent [denied / endorsed]. [Other behavioral risk concerns or "none reported"]
• Actions if risk signal positive: [Assessment performed / Team notified / Safety plan updated / Session modified / Emergency evaluation initiated]; Disposition: [Returned to unit / Discharged with plan / Referred to higher level of care] (Include only if applicable.)
• If safety not assessed: Reason: [Reason]; Mitigation: [Observed behavior, consultation, or other safeguard] (Include only if applicable.)
• Intervention appropriateness: Lyric analysis clinically appropriate given current acuity: [yes / no]. [If modified for safety, describe modification] (Note modification only if applicable.)

Intervention

Song: "[Song title]" by [Artist]; Selection: [clinician-selected / patient-selected / group vote]

Clinical rationale: [1–3 sentences connecting song themes to treatment goals or presenting symptoms]

Themes processed: [Theme]: [Brief anchor—patient quote or summary of stated connection]; [Theme]: [Brief anchor]; [Theme]: [Brief anchor] (Include only themes actually discussed.)

Coping skills targeted: [Skills]; Status: [taught / rehearsed in-session / assigned for practice]

Patient Response

Participation: [none / minimal / moderate / active / leading]; Engagement quality: [attentive / cooperative / guarded / distracted / oppositional / tearful / irritable]

Observable affect/behavior/communication: [Affect quality and intensity], [Behavioral observations], [Communication style or changes relevant to safety or treatment]

Response to music/lyrics: [Emotional reactions], [Cognitive responses such as insight statements or rigid thinking], [Behavioral response to skill coaching]. [Brief patient quote if clarifying] (For group sessions, document only this patient's response; refer to others as "peer.")

Assessment & Plan

Progress toward goals: [Progress / regression / no change] supported by [specific behavioral observations]

Insight: [limited / emerging / moderate / good], evidenced by [single justification]

Risk summary: SI [denied / passive / active]; HI [denied / passive / active]; Protective factors: [observed or stated factors]; Risk level: [low / moderate / high] (Include risk level if required by setting.)

Medical necessity: [One sentence explaining why credentialed clinician intervention was required] (Include when billed.)

• Next session focus: [Planned focus, modified based on today's response as indicated]
• Between-session practice: [Assigned exercise or skill practice] (Include only if assigned.)
• Care coordination: [Team members notified / collateral contacted / no coordination needed]
• Safety plan updates: [Updated elements or "no changes indicated"]
• Follow-up: [Date/timeframe], [in-person / telehealth], [individual / group]

Clinician Signature: [Name, credentials]    Date: [Date]

Supervisor Co-signature: [Name, credentials]    Date: [Date] (Include if applicable.)