Multiple-Family Group Psychotherapy Note

Date of Service: [Date]

Start Time / Stop Time: [Start time] / [Stop time]

Total Duration: [Total minutes]

Location/Setting: [Location or platform]

Modality: [in-person / telehealth]

Facilitator(s): [Name, credentials]

Diagnosis: [Diagnosis code and description]

Attendance

Identified Patient: [present / late / left early / no-show] (If late or left early, include times.)

Patient's Family Members Present: [Names and relationships] (If none, state "none.")

Other Family Units: [X other families, Y additional participants] (Do not include names or identifying details of other families.)

Total: [Total family units] family units, [Total participants] participants

Confidentiality reviewed: [yes / no] (Note any breaches or concerns addressed.)

Session Focus and Interventions

[Session theme/topic, therapeutic aim, and connection to the identified patient's treatment goals]

Interventions: [Specific psychotherapy interventions used with brief clinical rationale for each] (Examples: behavioral rehearsal, communication training, emotion regulation skills, family-systems reframing. Include only interventions actually delivered.)

(Note any significant deviations from planned content or unusual occurrences only if applicable.)

Identified Patient Assessment

(Combine subjective reports and objective observations; clearly distinguish reported vs. observed vs. clinical assessment.)

• [Current symptoms and interval changes reported by patient and/or family]
• [Homework or skills practice completion, if assigned] (Omit if not applicable.)
• [Clinician observations: appearance, affect, engagement level, and family interaction patterns during session]
• [Response to interventions: actions taken in-session, observable changes, skill attempts, insights, obstacles encountered]
• Progress toward treatment plan goals: [Goal(s) addressed with objective evidence of progress or lack thereof] (If a goal was not addressed, state "not addressed today." Note barriers if no progress.)

Risk and Safety

(Include this section only if suicide/self-harm/homicide risk, abuse/neglect concerns, or crisis content is present. Omit entirely if no risk indicators and organizational policy permits.)

• [SI/HI/self-harm: presence or absence with relevant details including intent, plan, means, precipitants]
• [Protective factors]
• [Actions taken: safety plan updates, referrals, crisis resources, mandated reporting status]

Plan

• [Next session date/time]
• [Homework or skills practice assigned] (Omit if none.)
• [Referrals or care coordination planned] (Omit if none.)
• [Modifications to treatment approach] (Omit if none.)

(Documentation guidance: Write in objective, behaviorally anchored language. Use direct quotes sparingly—only for clinically pivotal statements. Keep other families de-identified throughout; refer to them as "another caregiver," "peer adolescent," or "another family unit" when describing interactions. If required information is unavailable, use placeholders such as "not obtained" or "not assessed" with brief explanation. This is a clinical progress note, not psychotherapy notes as defined by HIPAA. If multiple identified patients from different families attended, create a separate individualized note for each.)