Template
The first section is for introducing the client. Please include the following information:
Agency Information
Client information (confidentiality of course)
Session Number
Date
Presenting Issue (reason for referral)
Relevant Information
Goal of Session
1. Client Goal
2. Your Goal
Dialogue
Please group dialogue together. Identify (for each section)
1. Theory
2. Tools
3. Skills Analysis/assessment of dialogue
What was going on? What were the patient’s reactions to your feedback? How did the client respond verbally (quality of voice, tone, did the respond better to closed or open-ended questions?) How did the client respond non-verbally (how did you know they were listening? were they distracted? Did they welcome your feedback?) Personal reactions and self-reflection to the interaction
What were you thinking? How do you feel the session went? What could you have done better? What will you do differently/the same next time?
