Substance Use Disorder Group Counseling Session Note

Encounter Details

Date of Service: [Date of service]

Session Time: [start–end / total duration]

Patient Time Present: [minutes present if different from full session]

Setting: [in-person / telehealth (video / phone)]

Group: [group name/type and topic/module]

Facilitator(s): [name(s) and credentials]

Attendance: [Present / Late / Left early / No-show / Excused]

(If No-show: complete only Encounter Details and No-Show Outreach section; do not document group content or assign homework.)

(For telehealth: document patient confirmed private location and note any connectivity issues.)

Confidentiality & Safety

Confidentiality reminder provided this session: [yes / no]

Boundary issues: [incident description without identifying peers; impact; corrective actions] (Include only if applicable. Never include names, initials, or identifying details of other group members.)

• Suicidal ideation: [denied / endorsed / not assessed] (If endorsed: document frequency, intent, plan, means access, protective factors, and actions taken.)
• Homicidal ideation: [denied / endorsed / not assessed] (If endorsed: document details and actions taken.)
• Intoxication/withdrawal concerns: [denied / endorsed / not assessed] (If endorsed: document substances, last use, objective signs, standardized measures if obtained, and actions taken.)
• Overdose risk factors: [denied / endorsed / not assessed] (If endorsed: document specific factors and harm reduction steps.)

(If any safety concern is endorsed: document protective factors, interventions, safety planning, and disposition.)

Session Content & Participation

Group topic/module: [topic/module name]

Session objectives: [1–3 key learning goals]

Facilitator interventions: [interventions delivered] (Use specific action language: guided discussion, modeled skills, facilitated role-play, provided psychoeducation, used motivational interviewing techniques.)

Patient report: [patient-reported cravings, triggers, stressors, recovery activities, relapse disclosures, substance use status, or "not discussed today"] (Include brief direct quote only if high-salience.)

Clinician observations: [appearance; engagement level: active / moderate / minimal; affect; interaction style; responsiveness to feedback] (If minimally participatory: note observable behaviors, facilitator efforts to engage, and patient response.)

Response to interventions: [insight gained; skills demonstrated; barriers identified; commitment statements; change talk observed] (Link to specific interventions.)

Group dynamics: [how peer interactions or group process influenced this patient's clinical status] (Brief, non-identifying description only.)

Assessment & Plan

Clinical assessment: [synthesis linking today's presentation to treatment goals; stage-of-change indicators; progress toward specific objectives; rationale for continued group participation] (Ground in documented observations and patient statements from this session.)

Plan: [home practice/skill assignments; relapse prevention steps; referrals/care coordination; next session focus] (Be specific about tasks, frequencies, and follow-up timeframes.)

Safety plan: [warning signs; coping strategies; supports; emergency resources; means safety; follow-up timeframe] (Include only if safety concerns identified above.)

(Use "not assessed" or "not discussed today" when information is missing rather than inferring.)

No-Show Outreach & Follow-Up

(Include only if Attendance is No-show.)

Scheduled group: [group name/type and topic/module]

Outreach attempts: [method(s), date/time, outcome]

Follow-up plan: [next steps; rescheduling; risk/safety check if indicated]

Signature

[Author name, credentials, role]

[Electronic signature with date/time]

[Co-signature/supervisor signature if applicable]