CBT-I session note template: sleep diary, sleep window and a worked example

A CBT-I session note is the written record of each appointment in a course of cognitive behavioural therapy for insomnia: weekly sleep diary averages, the sleep efficiency you calculated, the prescribed sleep window, adherence, techniques worked on and tasks until the next session.

The six components of CBT-I and what to note

Two texts are used here: the 2023 European Insomnia Guideline (Riemann et al., European Sleep Research Society) and the December 2006 recommendations of the HAS (the French national health authority) with the SFTG, older but precise on technique.

• Psychoeducation. The vicious circle of insomnia (staying longer in bed to make up for lost sleep). The HAS stresses first helping the patient think about why their insomnia persists. Note what was explained and what the client took from it.
• Sleep hygiene. Useful but not enough: the guideline states that "sleep hygiene on its own does not constitute an evidence-based treatment for insomnia". Note the two or three habits targeted, not a generic list.
• Stimulus control. The guideline describes "seven primary instructions" to break the learned link between bed and wakefulness. The HAS lists the core ones: go to bed only when sleepy; get out of bed if unable to fall asleep (or back to sleep) after 15 to 20 minutes; get up at the same time every morning, weekends included; keep the bedroom for sleep and sex only; avoid naps. Track each instruction separately: kept or not, on how many nights.
• Sleep restriction. Covered in the next section.
• Cognitive therapy. The guideline lists cognitive control, paradoxical intention, imagery training and cognitive restructuring, including "challenging negative thoughts by means of Socratic dialogue". Write the thought word for word, the alternative and the strength of belief before and after.
• Relaxation. The guideline cites "abbreviated progressive muscle relaxation, autogenic training and imagery exercises" and finds no evidence that one method is superior. Note the technique, how often and when it is practised.

Sleep efficiency and the sleep window: what you calculate

Sleep efficiency is total sleep time divided by time in bed, times 100. The HAS targets at least 85% and gives the example 320/450 x 100 = 71.1%, with average sleep time taken from a diary kept for at least 8 days. Always calculate on the weekly average and write both the figure and the averages behind it.

The sleep window is the time allowed in bed (bedtime and a fixed rise time). The guideline explains that sleep restriction "aims to restrict sleep opportunity and harness increased sleep pressure to consolidate sleep", that protocols differ on "minimum time in bed (e.g. 4.5, 5 or 6 hr)", and that time in bed is then extended, "often on a weekly basis". The HAS adjusts bedtime in 15-minute steps, keeps rise time fixed and never goes below 5 hours in bed.

An example of a published protocol, not an official rule: the CBTI-M manual (Cognitive-Behavioral Therapy for Insomnia in the Military, University of Arizona, revised 2019) titrates the window weekly as follows.

• Efficiency above 90%: 15 minutes more in bed.
• 85 to 90%: no change.
• 70 to 85%: 15 minutes less.
• Below 70%: total sleep time recalculated and times revised.

That manual sets a minimum of 5.5 hours in bed. Whatever protocol you use, we recommend writing the rule in the record from the session where restriction starts. The HAS warns that the technique is effective but hard at first, because sleep loss lowers daytime alertness; any time off work is for the GP to decide.

Sleep diary to copy

The HAS suggests a diary over one or two weeks. One line per night, filled in on getting up, using estimates: the client does not check the clock at night.

Fields for the client, every night

• Date and day (work day or not).
• Time into bed, time lights out.
• Estimated time to fall asleep (minutes).
• Number of awakenings and estimated total time awake.
• Time of final awakening, time out of bed.
• Naps or dozing (time, length).
• Coffee, tea, alcohol: amount and last time taken.
• Sleep medication taken: yes or no, name and time, as reported by the client.
• Sleep quality from 1 to 5, how they felt during the day from 1 to 5.
• Anything unusual (stress, illness, travel).

What you calculate afterwards

• Time in bed: bedtime to rise time.
• Total sleep time: time in bed minus time to fall asleep, time awake and time between final awakening and getting up.
• Sleep efficiency: total sleep time divided by time in bed, times 100.
• Weekly averages, nights completed, nights excluded and why.

Template, session 1: initial assessment

Header: client (initials or pseudonym), date, CBT-I session 1, length, referred by.

Presenting problem: falling asleep, staying asleep or early waking; how long; nights per week; daytime impact.

Usual sleep times reported: bedtime and rise time, weekdays and weekends (to be checked against the diary).

Maintaining factors: extra time in bed, naps, activities in bed, worry at bedtime, irregular hours, substances.

Reported treatments: what the client says they take and which doctor follows them, written as reported, without comment.

Points to pass on to the GP: reported snoring or breathing pauses, daytime sleepiness or sleepiness when driving, leg sensations, mood, history (epilepsy, bipolar disorder), pregnancy, shift work. Write "asked, absent" when that is the case.

Formulation: what triggered the insomnia and what keeps it going now.

Client goals: observable (for example "get back to sleep within 30 minutes on most nights").

Psychoeducation given: what was explained and how the client responded.

Tasks: sleep diary for at least 8 days, fixed rise time if already agreed.

Next session: date and what will be picked up.

Template, follow-up sessions

Header: session n of N planned, week of treatment.

Diary for the week: nights completed out of 7; averages (bedtime, rise time, time in bed, total sleep time, time to fall asleep, time awake); nights excluded and why.

Sleep efficiency: this week's figure and last week's.

Current window: times and start date.

Adherence: nights the window was kept, fixed rise time kept or not, getting out of bed done or not, naps.

Sleepiness and driving: question asked, client's answer.

Window decision: new window, rule applied, start date. Or "window unchanged", with the reason.

Session work: thought and alternative, relaxation, obstacles and solutions.

Goals: progress on each.

Tasks until next session and points to pick up.

Liaison: what was sent to the GP, and when.

Before closing the note, check that the window, its start date and the rule applied are there.

For a general CBT structure applied to another protocol, see our ERP for OCD session note template, and for the review letter at the end of treatment, our therapy progress report template.

Fictional example over 3 sessions

Claire is a fictional 47-year-old accountant referred by her GP for CBT-I.

Session 1, initial assessment

• Presenting problem: night waking 5 nights out of 7 for two years, starting after a change of job. Tired and irritable at work.
• Reported times: bed at 11 pm, up at 7.30 am on weekdays, 9 am at weekends.
• Maintaining factors: stays in bed awake "to rest anyway", phone in bed, Sunday nap.
• Checked: snoring, sleepiness when driving, epilepsy, bipolar disorder: asked, absent. Reported medication: none.
• Goals: get back to sleep within 30 minutes on most nights; feel well at work 4 days out of 5.
• Tasks: sleep diary for 8 days, up at 6.45 am every day including weekends.

Session 2, starting sleep restriction

• Diary: 8 nights out of 8. Averages: time in bed 8 h 30 (510 min), 50 min to fall asleep, 90 min awake at night, 30 min between final awakening and getting up. Total sleep time 340 min (5 h 40).
• Efficiency calculated: 340 / 510 x 100 = 66.7%.
• Decision: window set at 5 h 45, from 1 am to 6.45 am, starting tomorrow. Rule written in the notes: the CBTI-M rule (plus 15 minutes above 90%, no change at 85 to 90%, minus 15 minutes at 70 to 85%).
• Session work: stimulus control (get up after about 20 minutes awake). Thought noted: "if I sleep less than 8 hours I won't be able to work", belief 80%.
• Sleepiness: risk of lower alertness explained; Claire will tell her GP that restriction has started.

Session 3, adjusting the window

• Diary: 7 nights out of 7. Window kept 7 nights out of 7, rise time of 6.45 am kept all 7 days. Got out of bed on 3 of the 4 nights it was needed. One 30-minute nap on Sunday. 15 min to fall asleep, 10 min awake. Total sleep time 320 min (5 h 20) out of 345 min in bed.
• Efficiency calculated: 320 / 345 x 100 = 92.8% (66.7% the week before).
• Sleepiness: tired mid-afternoon, no sleepiness when driving reported.
• Decision: efficiency above 90%, window extended by 15 minutes under the rule in the notes, 12.45 am to 6.45 am, from today.
• Session work: restructuring the session 2 thought using her own figures (full working days on 5 h 20 of sleep), belief 45%. Started progressive muscle relaxation once a day, out of bed.
• Goals: back to sleep within 30 minutes 6 nights out of 7, met; feeling well at work 3 days out of 5.
• To pick up: the Sunday nap, the night Claire stayed in bed awake.

Common mistakes

• Not noting adherence. Rising efficiency means something different if the window was not kept.
• Not tracking the window. Without times and a start date, you cannot tell which window produced which figure.
• Calculating efficiency on one night, or without stating the averages used.
• Forgetting sleepiness, which the guideline asks clinicians to keep reviewing, including its impact on driving.
• Commenting on medication. Write what the client reports and send any question to the prescriber.

When to refer to the GP

Diagnosing other sleep disorders and any decision about medication belong to the doctor. We recommend writing to the GP as soon as one of the following appears, and keeping a copy of that letter in the record.

• Signs of sleep apnoea. The HAS lists loud snoring, daytime sleepiness, morning headaches and excess weight as suggestive symptoms, and advises referral to a sleep centre for sleep apnoea and restless legs syndrome.
• Insomnia that does not respond, or looks unusual. The HAS reserves sleep specialist referral for treatment-resistant insomnia and for unexplained, atypical or complex cases.
• Change in mood. The HAS notes that insomnia can be the first sign of a depressive episode or of a relapse of another psychiatric condition, including a manic state.
• Epilepsy and conditions made worse by sleep loss. The European guideline lists them as contraindications to stimulus control and sleep restriction: "any kind of epilepsy and conditions that might be aggravated by sleep loss".
• Sleepiness, especially when driving. The same guideline calls for "initial assessment for suitability and ongoing reviews of sleepiness (and impact on driving) during treatment".
• Pregnancy or comorbidities. NICE states that "a medical assessment should be done before referral to Sleepio" for people at higher risk of other sleep disorders, "such as in pregnancy, or in people with comorbidities".

Why Delta fits a CBT-I course

CBT-I depends on continuity: the window in session 4 depends on the figures from sessions 2 and 3. Delta is the clinical assistant that keeps the memory of each client. It writes the session report from what is said in session or from what you dictate afterwards, takes the CBT approach into account, and updates the client record (summary of the therapy, goals tracked). You do the calculations; Delta keeps track of your figures, decisions and topics to pick up, and calculates no score.

Data stay in Europe, in France, on infrastructure certified for health data; the client's name is pseudonymised before the AI, and no audio file is kept. There is a free plan (10 sessions a month) and a Pro plan at €29 a month billed yearly or €35 billed monthly, VAT included. See also our counselling session notes template and all our clinical document templates.

Sources

• Riemann D. et al., The European Insomnia Guideline: an update on the diagnosis and treatment of insomnia 2023, Journal of Sleep Research, 2023 (open access full text).
• NICE, Sleepio to treat insomnia and insomnia symptoms (MTG70), 2022.
• HAS and SFTG, Management of adults complaining of insomnia in general practice, recommendations (in French), December 2006.
• CBTI-M, Insomnia Treatment Manual, Therapist Materials, University of Arizona, revised February 2019.