The forms a session actually needs

Establish, in writing and in conversation, what the patient is agreeing to before treatment begins.

24 fields · Before or during the first session, and revisited whenever the frame changes.

Cover the risks and logistics that remote delivery adds to ordinary informed consent.

8 fields · Before the first remote session, and again if the patient relocates.

Record a specific, time-limited, revocable authorisation for a named disclosure.

8 fields · Before any communication with a third party — GP, psychiatrist, school, employer, family member, prior therapist.

Gather the history needed to formulate, plan, and assess risk — without turning the first meeting into an interrogation.

62 fields · Sessions 1–2, completed across the conversation rather than read off a list.

A structured description of the patient’s mental functioning at this moment — the psychological equivalent of a physical examination.

22 fields · At intake, at any point of clinical change, and whenever risk is assessed.

Bring the patient’s own cultural framing of their problem into the formulation instead of assuming it.

15 fields · Early in assessment; essential whenever clinician and patient differ in background, and useful when they do not.

Identify what a behaviour is actually doing for the person, by mapping antecedents, the behaviour itself, and its consequences.

14 fields · Whenever behaviour is the target — avoidance, self-harm, compulsions, substance use, anger, procrastination.

Reconstruct a problem episode link by link so that solutions can be inserted at specific points.

13 fields · After a self-harm, crisis, or target-behaviour episode — a standard weekly practice in DBT.

Map the patient’s significant relationships and locate the interpersonal problem area that will focus the treatment.

10 fields · Sessions 1–3 of interpersonal psychotherapy; useful in any relational approach.

Form and record a clinical judgement about risk, and decide what to do about it.

31 fields · At intake, whenever risk is disclosed or suspected, at any deterioration, and around transitions of care.

A written, prioritised list of coping strategies and supports the patient can use when a crisis builds.

17 fields · Whenever suicidal ideation is present. Built collaboratively, in the patient’s own words, before they leave.

Assess threat toward others and decide whether a legal duty to warn or protect has been triggered.

17 fields · Whenever a patient expresses intent, threat or fantasy of harming another person.

Record the reasoning and the action when suspected abuse or neglect arises.

15 fields · Whenever information raises suspicion of abuse or neglect of a child, older adult, or dependent adult.

A theory-neutral scaffold for organising why this person, why this problem, why now, and why it persists.

15 fields · After assessment, before treatment planning. The best starting formulation for a trainee in any modality.

Extract the recurring relational pattern — wish, response of other, response of self — that organises the patient’s difficulties.

15 fields · Sessions 2–5 of psychodynamic work; revised continuously.

Link early experience, core beliefs, rules and strategies to the specific situations that trouble the patient now.

14 fields · From session 2 onward, built with the patient and revised as evidence accrues.

Locate psychological inflexibility across six processes and identify the workable direction.

12 fields · Early and throughout; ACT formulation is functional and continuous rather than a one-time document.

Specify target behaviours, their controlling variables, and the contingencies that will change them.

12 fields · Behavioural and exposure-based treatments; any presentation where avoidance is central.

Track the conditions, the client’s process level, and the therapist’s own congruence — the person-centred alternative to formulating about a client.

13 fields · After sessions, in supervision, and in personal development work.

Locate the problem in the relational system rather than in the individual.

17 fields · Family and couple work; also useful in individual therapy where the family is the operative context.

Combine the levels of explanation coherently, and state the reasoning for each borrowed element.

14 fields · Complex presentations; any case where a single-school formulation leaves too much unexplained.

State what you are trying to change, by what means, measured how, and by when.

15 fields · After formulation, usually sessions 2–4; reviewed at agreed intervals.

Build a graded list of feared situations and record what actually happens on exposure.

7 fields · Anxiety, OCD, PTSD and phobia treatment, from the first exposure session onward.

Monitor and then plan activity, breaking the withdrawal–low mood spiral.

5 fields · Depression, from the first or second session; usually before cognitive work.

Teach the patient to catch, examine and re-evaluate an appraisal, rather than to argue with themselves.

11 fields · Cognitive therapy, from roughly session 3, once automatic thoughts can be identified.

The standard medical-record note format: subjective, objective, assessment, plan.

11 fields · After every session, in settings that use SOAP.

Alternative note structures used in behavioural health and community settings.

14 fields · Where your service specifies one of these formats.

Record missed sessions, outreach, and any contact outside the session.

8 fields · Every no-show, cancellation, phone call, message or third-party contact.

Solicit the patient’s view of the session and of the alliance, so that drift and rupture are caught early.

11 fields · Last two minutes of every session, or at minimum every third session.

Identify alliance ruptures, classify them, and record the repair attempt and its outcome.

12 fields · Whenever the alliance strains — which is often, and more often than trainees notice.

Track your own reactions so they become information rather than unexamined influence.

12 fields · After any session that stayed with you — the ones you dread, the ones you enjoy too much, the ones you cannot stop thinking about.

Close the treatment properly: what happened, what changed, what remains, and what to do if it returns.

14 fields · The final sessions of a planned ending, and after an unplanned one.

The patient’s own summary of what they learned and what they will do when it comes back.

12 fields · Final three or four sessions; written by the patient, not the therapist.

Prepare a case for supervision so the hour is spent on the question rather than on the history.

15 fields · Before supervision; mandatory for risk, ethical questions, ruptures, and non-response.

Work through an ethical question systematically and leave a record of the reasoning.

16 fields · Any time you notice that a decision has an ethical dimension and the answer is not obvious.

Structure the repeated, feedback-driven rehearsal that actually improves clinical skill.

12 fields · Ongoing professional development, ideally weekly.

Apply one theoretical perspective to a case and produce a defensible brief treatment plan.

17 fields · As a written assignment, and as the discipline behind every real treatment plan.

Decide whether a specific study supports its own conclusion — and be able to say why in a seminar.

27 fields · Journal clubs, article discussion assignments, and before citing anything you have only read the abstract of.

Establish, in writing and before you know much, what you already believe about how people change.

21 fields · At the start of a survey course. Kept, and re-read at the end.

Turn a topic into an argument, and a search into something you can describe.

19 fields · Before reading widely. Revised as the argument takes shape.

Get the architecture right before writing, so the paper argues rather than reports.

28 fields · After the analysis, before the first draft.

Pre-specify the review, so that the method is a method rather than a description of what you ended up doing.

19 fields · Before the search. Registered on PROSPERO before screening begins.

Make the case that the question matters, the method can answer it, and the risks are managed.

22 fields · Dissertation proposals, funding applications, and IRB / research ethics committee submissions.

Record a specific, informed, revocable consent before writing about a real person — and think properly about whether to.

13 fields · Before drafting any case report, conference presentation, book chapter or teaching material based on an identifiable patient.