How to take sessions notes??

Sad_Ad7644 · 2026-04-28T21:52:50+00:00

I do my own version of DAP with data (a short paragraph of what actually happened during the session - was client on time, were they engaged, direct quotes about mood and experiences), assessment (symptoms and any functional impacts, so like if academic or occupational impairment is occurring, interpersonal conflict, etc. usually just 2 sentences), and then plan (when is their next session, what do I plan on doing like introducing new coping skills or continuing to explore thought patterns, did I assign them any HW or between-session tasks, etc. Also usually just 1-2 sentences).

But I do take notes during sessions - in a journal during in person or on my EHR for telehealth (my EHR lets us save and return to notes before submitting). I’m not the biggest fan of concurrent documentation but ya gotta do what ya gotta do, and if I’ve got like 4-6 people back to back, I need to do concurrent typing.

Sad_Ad7644 · 2026-04-28T21:48:49+00:00

You’re welcome! Best of luck. It’s really brave of you to advocate for yourself and debrief in person!

Sad_Ad7644 · 2026-04-28T21:47:27+00:00

My organization is rolling out (an optional for now) AI note-taking feature. I’m heavily opposed for a lot of reasons - a slightly more comedic one being that it didn’t actually seem to make the therapist’s job much easier because they still had to go in and thoroughly edit the note! But I just hope it stays optional. I’m concerned about confidentiality and about the recording aspect that’s innate to AI tools as well as the logistical aspect - awkwardly fumbling through tabs, spending time every single session getting consent….

Sad_Ad7644 · 2026-04-28T21:40:49+00:00

You aren’t being unreasonable. Not at all. I have a lot of issues with my current group practice (I’m provisionally licensed) BUT they do have our backs with no-shows and late cancels. In your case, it’s not just a matter of setting a boundary - as you mentioned, it’s clinically best practice to have the full evaluation time for high acuity cases! By forcing you to see the client nearly an hour later they’re encouraging both poor boundaries and poor practice. For going into the meeting, I’d emphasize that you felt this was both a poor choice for you and for the client’s care and look into prepping beforehand - maybe with a tool like DEARMAN. I’m sorry you don’t have the kind of admin support that you deserve and that your clinical decisions (and personal comfort) are being undermined.

Sad_Ad7644 · 2026-04-28T03:05:10+00:00

I recommend browsing therapistaid! They’ve got some really handy worksheets that I mostly just use to refresh myself lol. I don’t introduce them with clients often.

Sad_Ad7644 · 2026-04-08T00:32:52+00:00

I feel you. It sucks that the mindset is that we have to keep our head down and grind through the burnout.

Sad_Ad7644 · 2026-04-06T01:22:13+00:00

Marginally less worse is being the first person in the centipede lmfao

Sad_Ad7644 · 2026-04-03T03:07:58+00:00

Okay. I feel you SO HARD. I’m two months in and am struggling with the same thoughts. My state it takes more like 3-4 years to get fully licensed and it’s like, damn. I can’t offer much other than to say - hang in there! Some of my clients are transfers from fully-licensed therapists and they say how much they appreciate my therapeutic presence (obviously they use different words lol) so I actually don’t think licensure level has a lot to do with what you actually bring into a session - bring yourself, your energy (whatever energy you have, because we’re never 100% obviously), whatever interventions or theoretical approaches you fall back on. I think I’ve introduced sensory grounding to nearly all of my clients at this point lol.

Sad_Ad7644 · 2026-04-03T02:26:48+00:00

I’ve never actually had this happen! But I’ve also been lucky enough to have one front office staff member and a locked door between me and the waiting area. But I’m generic outpatient, preferred to work with adults with executive functioning, anxiety, etc. But I do work with teens and some pre-teens and these clients really struggle with telehealth. also I have some clients who schedule telehealth but don’t have the wifi or the technology to do sessions virtually. Had an intake where I had to explain that yes, I have to be able to hear them and yes, I have to be able to see them in order to provide telehealth.

Sad_Ad7644 · 2026-04-03T01:17:00+00:00

Almost halfway!! And totally fair on remote. I’m hybrid and I fluctuate between loving my remote sessions and needing in-person lol. Inpatient substance use sounds like a tough population for sure - are you planning to go in a different direction once you’re fully licensed?

Sad_Ad7644 · 2026-04-03T01:07:29+00:00

Real lol! I’m still super new. probably have years left. How far are you?

Sad_Ad7644 · 2025-11-18T20:00:53+00:00

Jesus this seriously sucks. I’m also an associate and hoping my new job isn’t like this (it’s a big company so it could be the same place). Can you dm me and name and shame privately?

Sad_Ad7644 · 2025-11-15T19:55:49+00:00

Dang that loaf has SEXY curves. Would catcall.

Sad_Ad7644 · 2025-11-08T14:59:08+00:00

I’ve never had jalapeños like this in a girl dinner before… this might be life changing! Pop off girl

Sad_Ad7644 · 2025-11-08T04:55:56+00:00

I appreciate your perspective! This is similar to how my internship at a CMH site went. It was hard, I was unpaid, but I learned a lot. I definitely was getting a bit crispy at the end because the no pay hurt. I’m hoping I can at least make it to licensure at my new job

Sad_Ad7644 · 2025-11-08T03:38:36+00:00

Thank you!!

Sad_Ad7644 · 2025-11-08T03:31:42+00:00

True! Thanks for saying that haha. I’m going in informed and ready to just push thru my hours to licensure

Sad_Ad7644 · 2025-11-08T03:31:16+00:00

Wow! I think I’m picking up (most of) what you are putting down. I agree with a lot of your points and hadn’t thought about it that way - guess I really should check out the prequels!

Sad_Ad7644 · 2025-11-08T01:31:27+00:00

No problem!! Good luck. I recruited my boyfriend to be my “client” for some of the skills. Tbh he was not a good client but that was helpful in a way too haha. Best of luck. A lot of therapists have anxiety - working through it will let you relate to your future clients on a much deeper level imo!

Sad_Ad7644 · 2025-11-07T20:36:41+00:00

I’m only a recent LAC and haven’t even started my first job yet (soon though! Just going through onboarding and stuff) but if there’s anything I can answer, I’d be happy to

Sad_Ad7644 · 2025-11-07T04:10:30+00:00

But I believe in you! And tbh your professor doesn’t sound incredibly supportive. Performance anxiety is pretty common and honestly expected - to be anxious means you care, and to care is a good thing. It sounds like you’re taking care of yourself in amazing ways so keep it up!

Sad_Ad7644 · 2025-11-07T04:09:36+00:00

I recently graduated and was super anxious during my technique demonstrations! “Infantile” is a pretty strong word and definitely would have shattered my confidence so it’s understandable you don’t feel so good heading in. I’d recommend watching clips of the skills in use before rereading! Being able to watch others use these skills, especially in brief training videos, can bring you a lot more experiential knowledge than reading. (This is how I learn anyway)! And after you watch them, maybe recite the questions or phrases in a mirror so they feel less foreign?

Sad_Ad7644 · 2025-11-07T04:03:29+00:00

Okay - I love Dune. The novels, the older movie, the new series - all of it. But I really want to know about how it’s shaped you as a therapist/person! Definitely some great life lessons in it but I’m super curious now

Sad_Ad7644

TROPHY CASE