Psychotherapy Process Note (Play Therapy)

PSYCHOTHERAPY NOTE (PROCESS NOTE) — Not Part of the Designated Medical Record | Restricted Access — For Treating Clinician Use Only

Patient: [initials or MRN]

Date of Service: [date]

Clinician: [name and credentials]

Present: [categories of attendees] (Avoid third-party full names.)

Clinical Context

[Brief 1–2 line context anchor for clinician's process reflections] (Omit if not relevant. Do not include diagnosis, symptom lists, treatment plan goals, or progress summaries.)

Session Process

(Capture process and sequence using respectful, behavioral descriptions. Include brief child quotes only when uniquely meaningful. If information is unavailable, note briefly.)

Play episodes

• [Concise behavioral description of materials chosen, approach, and what unfolded] (Include 2–4 key moments as applicable.)

Themes observed

• [Emergent symbolic themes as working observations, e.g., safety/danger, power/control, loss/reunion, nurturance, identity/role exploration] (Tentative, not conclusions.)

Affect and regulation

• [Shifts in arousal, frustration tolerance, affect states linked to specific moments]

Relational process

• [Attachment markers, bids for attunement, limit-testing, misattunements/repairs, therapist stance used]

Therapist Internal Process

(Private reflections not appropriate for the medical record.)

Reactions

• [Countertransference feelings, somatic cues, therapist impulses] (Use reflective language.)

Hypotheses

• [Provisional working formulation tied to observable play/process] (Label clearly as hypothesis, e.g., "Hypothesis: repeated 'locked room' play may reflect attempts to control unpredictability.")

Questions to hold

• [What to explore next session; what was avoided; curiosities about the child's process]

Safety and Reporting Gate

(Do not place the sole record of safety events in this note.)

• [ ] No safety concerns arose requiring documentation outside this note
• [ ] Safety concern arose — documented in clinical record (see progress note dated: [date])

• [ ] No mandated report issues identified
• [ ] Mandated report made/considered — documented in clinical record per policy

Prohibited in this note: session start/stop times; billing codes; modality/frequency language; medication details; test results; diagnosis; functional status; treatment plan; prognosis; progress summaries. If needed for care continuity, billing, or safety — document in the clinical record.