Stress Management/Relaxation Session Note (Recreational Therapy)

Date of Service: [date]

Provider: [name, credentials (e.g., CTRS)]

Session Format: [individual / group]; [in-person / telehealth]

Duration: [total minutes]

Setting/Location: [setting/location]

Subjective

[Pre-session stress/anxiety rating and scale used (e.g., 0–10)] [Current stress-related symptoms] [Specific triggers or stressors addressed: anticipatory and/or retrospective] [RT or interdisciplinary goal(s) addressed today, written in functional terms]. (Write as a brief narrative paragraph using a consistent rating scale across sessions. If the patient cannot identify triggers, state this explicitly and document observable antecedents instead. If pre-session rating not obtained, document reason.)

Intervention & Response

[Relaxation technique(s) used by name] [Practice dose: approximate duration or number of rounds]. [Skilled coaching provided: specific cues, pacing, positioning guidance]. [Adaptations applied: trauma-informed modifications, eyes open vs. closed, simplified steps, shortened duration, sensory or environment adjustments]. (Name each technique explicitly. Include only interventions delivered today.)

[Participation level: active / prompted / passive] [Ability to follow directions: independent / minimal cues / moderate cues / maximal cues] [Observable response during practice: affect, posture, behavioral indicators] [Post-session stress/anxiety rating (same scale as pre-session)] [Skill acquisition: patient can describe or demonstrate technique with minimal cueing: yes / emerging / no] [Barriers encountered, if any] [Adverse responses and actions taken / no adverse response observed]. (If no barriers or adverse responses occurred, include a brief statement to that effect.)

Assessment

[RT clinical interpretation summarizing progress toward goal(s), rationale for technique selection for this patient, and skilled expertise required (grading, adaptation, engagement strategies, trauma-informed approach)]. (Keep to 2–4 sentences; avoid repeating objective details verbatim.)

Plan

• [Next session focus: technique progression, new trigger focus, and/or independent practice coaching]
• [Home practice assignment: specific technique, frequency, duration, and situational triggers for use]
• [Resources provided, if any: handout title, app name, or other materials]
• [Interdisciplinary communication or referrals, if applicable]
• [Anticipated follow-up timing]

Provider Signature: [name], [credentials]  |  Date/Time Completed: [date/time]

(Omit items that do not apply to this session. If any expected information is unavailable, document the reason explicitly rather than leaving blank.)