Data
- Observations of the client’s mood and appearance
- Speech patterns and general behavior
- Key statements or themes that emerged during the session
Assessment
- Clinical interpretation of the session data
- Insights on client progress or challenges
- Notable symptoms or changes observed in the client
Plan
- Outline of next therapeutic steps
- Specific interventions or techniques planned
- Goals, homework, or assignments for the client
- Follow-up topics or objectives for the next session