School-Based Session Note (Play Therapy)

(Keep the note scannable and brief. Use short paragraphs or compact bullets. Label play themes as impressions. Avoid verbatim dialogue or play-by-play content. If information is unavailable, briefly note why rather than leaving blank.)

Student: [name or initials per policy]

DOB/ID: [date of birth and/or student ID]

Grade/Teacher/School: [grade level, classroom teacher, school name]

Date of Service: [calendar date]

Session Time: [start time – end time / total minutes]

Location: [room/setting]

Service Type: [individual play therapy / dyadic / group / crisis]

Provider: [name, credentials, supervision status if applicable]

Record Context: [education record per FERPA / clinical record]

Consent: [on file / date obtained] (Note student assent if documented.)

Session Focus

• [School-relevant reason for session] (e.g., emotional/behavioral concern impacting learning, IEP/504 minutes, peer conflict)
• [Primary target(s) addressed] (1–3 concise targets)
• [Goal linkage] (Reference IEP/504/counseling plan goal if applicable; otherwise note rapport-building or assessment phase)

Objective

(Observable, behaviorally anchored descriptions only.)

• Presentation: [appearance, behavior, demeanor]
• Affect: [range, valence, stability as observed]
• Attention/Regulation: [on-task behavior, distractibility, arousal level]
• Play Observations: [engagement with materials, limits needed, observed themes] (Label themes as impressions.)
• Relational Stance: [approach toward therapist: collaborative / avoidant / controlling / dependent]
• Transitions: [transition to session; regulation upon return to class; supports needed]

Intervention & Response

• Approach: [child-centered / directive / TF-CBT-informed / integrative] (One-line summary.)
• Techniques: [techniques used this session] (e.g., tracking, reflecting feelings, limit setting, sand tray, role-play, coping skills)
• Student Response: [participation level and openness to intervention]
• Progress Toward Goals: [statement with concrete example tied to school functioning] (e.g., class participation, peer interaction, task initiation)
• Barriers: [attendance, privacy, avoidance, logistical factors] (Only if applicable.)
• Educational/Functional Impact: [connection between session work and classroom engagement, peer functioning, or school routines]

Safety

• [No acute safety concerns endorsed or observed.] (Use when appropriate.)
• (If concerns present, document concisely):
  • Risk Details: [SI/SH ideation, intent, plan, access to means; harm to others; abuse/neglect disclosure; protective factors]
  • Actions Taken: [caregiver contacted, safety plan created/updated, mandated report filed with date/agency, crisis protocol followed]
  • Disposition: [returned to class / escort to caregiver / emergency services]

Plan

• Next Session Focus: [1–2 targets for upcoming session]
• Between-Session Supports: [classroom strategy, coping tool, caregiver involvement, or none] (Include any tools or instructions provided.)
• Coordination: [teacher consult, IEP team, outside provider] (Note what was shared and under what consent/authorization.)
• Referrals: [school or community resources] (Only if indicated.)
• Next Appointment: [date/time / scheduling pending with reason]

Provider Signature: [electronic signature, credentials, date/time]