Brief therapy session notes: what to write and a template

A brief therapy session note is a short, dated written trace of what drives a time-limited treatment: the patient's request, the goal they have stated in concrete terms, the problem as they experience it, what they have already tried, the times when the problem does not happen, their own ratings on a scale, and the tasks set between sessions with their outcome.

This article is for therapists, psychotherapists and psychologists who practise brief therapy, whether strategic (in the Palo Alto tradition) or solution-focused, in France, Belgium and Switzerland. If you use Ericksonian hypnosis, see our dedicated article on hypnotherapy session notes.

Why brief therapy needs its own note

In brief therapy, the work targets a specific problem and an observable change, often within a limited number of sessions. The note should let you answer three questions as soon as you open the file: what does the patient want, what has already been tried, and what has moved since last time.

The two main schools look at different things. The strategic approach that came out of the Mental Research Institute in Palo Alto focuses on what the patient and those around them do to solve the problem. On the Institut Gregory Bateson website, an article quotes Fisch, Weakland and Segal: every problem is maintained by the very efforts the client and those around them make to solve it. The solution-focused approach looks for what already works and what the patient wants to see instead of the problem. The template below leaves room for both.

What a brief therapy note tracks

1. The request and a concrete goal

Note who is asking and what is asked, with the patient's own words in quotation marks. Then write the goal in observable terms. The Solution Focused Brief Therapy Association treatment manual (2013) says goals should state positively what clients will do rather than what they will not do. So write "take the metro to work alone" rather than "stop being afraid".

2. The problem and attempted solutions

Describe the problem as a concrete sequence. Then list what the patient and those around them have already done to fix it, and what happened. In the Palo Alto approach, this list is often the heart of the note, because it shapes the intervention. An Institut Gregory Bateson article recalls Watzlawick's phrase, "le problème, c'est la solution" (the problem is the solution).

3. Exceptions

The SFBTA manual defines an exception as a time when the problem could have happened but did not. Note them with the context and what the patient did differently.

4. Scales rated by the patient

Scaling questions, often from 0 to 10, place the patient relative to their goal, motivation or confidence. Write down the number the patient gives, the exact question asked, and what they say "one point higher" would look like. It is a subjective rating, not a test, so there is no score to calculate. Keep the same wording from session to session so the comparison makes sense.

5. Between-session tasks and their outcome

Write down the task or prescription as you phrased it and whether it was accepted, then at the next session what the patient did with it and what they noticed. The SFBTA manual describes, for example, a first-session observation task inviting the client to notice what happens in their life that comes closer to what they want.

6. Planned number of sessions and review

Many practitioners set a frame at the start (a number of sessions, or a review point on a set date) and sometimes plan a spaced-out consolidation session. This is common practice, not a rule shared by every institute. If you set a frame, note it, along with each review point and the reason treatment ended.

Brief therapy session note template

Not every section is needed every session.

Follow-up session template

• Identification: patient (initials or file number), date, session number out of the planned total.
• Since last session: what has improved, even slightly, according to the patient.
• Previous task: done, partly done or not done, and what the patient noticed.
• Problem: recent situations, described as concrete sequences.
• Attempted solutions: new attempts by the patient or those around them, and their effect.
• Exceptions: times when the problem did not happen and what was different.
• Scales: question asked and number given by the patient, compared with the previous session.
• Interventions: reframing, questions, suggestions made in session.
• Task set: exact wording and the patient's response.
• Next steps: next session date, review point, topics to come back to.

Example first-session note

• Session 1 of 5 planned, review at session 3. Referred by her GP.
• Request: "I can't take the metro any more, and I need to manage it to keep my job."
• Concrete goal: travel alone by metro from home to work, three days a week.
• Problem: for four months, turns back as soon as she sees a crowded platform. Takes a taxi, arrives late.
• Attempted solutions: reasoning with herself ("it's nothing"), asking her partner to come along, avoiding rush hour. These reduced the trips but not the fear.
• Exceptions: took the metro one Sunday with her sister, "without thinking about it".
• Scale: 3 out of 10 for "where you are with your goal". One point higher would be "going down to the platform without turning back".
• Task: notice what is different on days when the trip goes slightly better. Accepted.

Example end-of-treatment note

• Session 5 of 5, final session.
• Initial goal: travel alone by metro three days a week. Reached for two weeks, according to the patient.
• Scales: 3 out of 10 at session 1, 8 out of 10 today, numbers given by the patient.
• What helped, in her view: stopping forcing herself to "feel nothing", planning a short first stop.
• Points to watch, as she named them: strike days, unfamiliar routes.
• Next steps: no further session planned. Consolidation session offered in two months if she wishes.

What to leave out

• Interpretations written as facts. Label your hypotheses as such.
• Details about third parties (partner, colleagues, children) that do not serve the treatment.
• Judgements about the patient or their motivation.
• Diagnoses outside your field of competence.

We advise writing each note as if the patient might read it one day. For a comparison of general note formats, see SOAP, DAP and BIRP notes. If you see couples or families, the systemic family therapy note will fit better.

Confidentiality and health data

Professional secrecy

Article 226-13 of the French Criminal Code punishes the disclosure of secret information by a person who holds it through their status or profession, with one year of imprisonment and a 15,000 euro fine. For therapists whose title is not regulated, whether this article applies has not been settled. We advise acting as if you were bound by secrecy, for all your notes. Our article on professional confidentiality and AI covers this in detail.

GDPR

Your notes contain health data. Article 9 of the GDPR, published on the CNIL website, places this data in a special category whose processing is prohibited, with exceptions, including health or social care, provided in particular that the data is processed by a health professional bound by professional secrecy or under their responsibility. We advise keeping the note to what serves the treatment and choosing hosting suited to health data. The GDPR applies in France and Belgium. In Switzerland, check the applicable federal law.

How Delta can help

Delta is the clinical assistant for mental health and allied health professionals. You choose how to take your notes. During the session, Delta transcribes what is said. Or, after the session, you dictate your observations. You can also add written notes.

Delta then generates the session report (short summary, detailed summary, topics for the next session). It takes your profession and your approach into account. It updates the patient record, with a summary of the treatment and the goals being tracked, so you can find the whole treatment and how it has evolved in one place. Scale numbers stay the ones the patient gave: Delta does not calculate scores. Delta also drafts letters, certificates and assessment reports.

Data is hosted in France by an HDS-certified host, and AI processing takes place in France. The patient's name and identifying information are pseudonymised before the AI. No audio file is kept, data is never used to train a model, and it is encrypted in transit and at rest. Delta works in the browser, with a Mac and Windows app recommended in session. For an overview, read what Delta is, and browse our clinical document templates by profession.

Sources

• Institut Gregory Bateson, "Les quatre nobles vérités de la thérapie brève", G. Delannoy, 26 May 2025 (in French)
• Institut Gregory Bateson, "Le problème, c'est la solution", G. Delannoy, published 2020, updated 8 April 2025 (in French)
• Solution Focused Brief Therapy Association, treatment manuals (2nd edition, 2013, English and French)
• Légifrance, French Criminal Code, article 226-13
• CNIL, GDPR, chapter II, article 9