BIRP Note Example

Navigating Gender Identity

Client is exploring their gender identity and seeking guidance on self-acceptance.

Generated BIRP Note:

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Behavior:
Client presented to the 60-minute session appearing a little nervous, discussing concerns about their gender identity and feeling uncertain about 'where I fit in.' Client's family expectations have exacerbated their confusion about self-expression, leading to feelings of isolation and anxiety.

Intervention:
The session was conducted at the office. Explored client's fears, particularly the fear of rejection, and discussed the importance of self-acceptance as a gradual process. Therapist suggested journaling to track feelings and identify comfortable moments in their identity, and recommended seeking safe spaces for identity exploration.

Response:
Client acknowledged their fear of rejection and expressed a desire to 'feel like I’m being real, not hiding all the time.' They were receptive to the idea of journaling and considering finding nonjudgmental communities.

Plan:
The therapist and client agreed to reconvene in two weeks to review the client's feelings and progress with journaling. The continuation of the treatment plan will focus on supporting the client's exploration of their gender identity.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over.

We had a 60-minute session today at the office. Client came in looking a little nervous, said they’ve been questioning their gender identity for a while now, and it’s been really weighing on them. They said quote 'I don’t know where I fit in' unquote. We started talking about how they feel really confused about expressing themselves and how family expectations have been making it worse. They mentioned that their family’s pretty traditional, and it’s making them feel stuck, like they can’t be who they really are. They talked about how they’ve been feeling kinda isolated and anxious because they don’t know how people in their life will react. It was pretty heavy.

We dove into some of those fears, and I could tell that the fear of rejection has been a big thing for them. We talked about how self-acceptance is not something that happens overnight, and it’s a process. They said quote 'I just want to feel like I’m being real, not hiding all the time' unquote. I suggested they start keeping a journal to write down their feelings and maybe even track moments where they felt the most comfortable in their identity—just to reflect. They seemed pretty open to that idea. We also talked about finding spaces or communities where they feel safe to explore their identity without judgment, because that could help ease some of this anxiety.

They seemed kinda relieved by the end of the session, like they finally have a direction to start working through this. We’re gonna meet again in two weeks to see how they’re feeling and how the journaling is going.

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