Music Therapy Group Session Note

Date: [Date]

Start/End Time: [Start time] – [End time] (If not captured, enter "[see scheduling record]")

Setting/Location: [Setting/Location]

Facilitator: [Name, credentials]

Group Name/Type: [Group name/type]

Session Number: [Session number] (If not tracked, omit line.)

Attendance: [# present] present; [# absent] absent

Reason for Service: [Link to plan of care or treatment domain]

Group Session

[Concise narrative (3–6 sentences) summarizing: session theme/topic; clinical intention and targeted needs; intervention categories and key techniques used; notable adaptations; and overall engagement/dynamics including cohesion, responsiveness, or disruptions.] (Use non-identifying language such as "peers" or "another member"—never names. Do not reproduce song lyrics.)

Individual Response

(Document for this participant's medical record only. Use objective, observable language. Include only content assessed today.)

• Presentation/Status: [Affect, alertness, communication style, notable observations] (Include only if clinically relevant.)
• Participation Level: [active / moderate / passive / declined]; [independent / cues needed]; [observable behaviors demonstrating engagement]
• Response to Interventions: [Observable changes during/after specific techniques; facilitators that supported success; barriers encountered]
• Progress Toward Goals: [Objective indicators linked to treatment goals with counts, durations, or scale scores as available]; progress: [improved / stable / worsened] relative to [baseline / prior session] (Only compare if explicitly known.)
• Safety: [no acute safety concerns] (If concern present, document observations, actions taken, and disposition. If not assessed, omit line.)

Plan

• Group Continuation: [continue current approach / modify—brief rationale]
• Individual Follow-up: [follow-up needs, referrals, or goal updates as indicated]
• Team Coordination: [communication with care team if occurred] (Omit if none.)
• Homework/Practice: [assigned practice or strategy] (Omit if none.)

Clinician Signature: [Name, credentials] — [Date/time signed]

Co-signature/Supervisor: [Name, credentials] — [Date/time signed] (Include only if required.)