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DBT session note template
Use this for individual DBT sessions where diary card review, target hierarchy, skills coaching, and brief chain analysis need to stay organized and stage-appropriate.
Template content
Copy or download, then paste into Wavo under My Templates.
DBT Session Note Session Information - Modality, duration, stage of treatment if tracked, and session focus. Diary Card Review - Emotions, urges, skills used, and target behaviors logged since last session. - Patterns or missing data discussed (without inventing card contents). Target Hierarchy Addressed - Life-threatening behaviors, therapy-interfering behaviors, quality-of-life targets—as prioritized today. - Brief chain analysis elements if completed (prompting event, links, consequences, skill alternatives). Skills Coaching - Modules/skills taught or practiced (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness). - In-session rehearsal and coaching notes. Dialectics / Validation - Validation strategies used and dialectical dilemmas addressed if relevant. Risk / Safety - Current SI/NSSI/HI urges, actions, and safety plan status if assessed. - Coaching for crisis survival skills when indicated. Client Response - Engagement, skill understanding, commitment, and barriers. Plan / Homework - Skills practice assignments, diary card completion, coaching call parameters if used, and next session focus.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Follows DBT individual session flow: diary card → targets → skills → homework.
- Keeps life-threatening and therapy-interfering behaviors first-class when present.
- Documents specific skills taught/practiced (mindfulness, distress tolerance, emotion regulation, IE).
- Supports chain analysis without forcing a full protocol every visit.
- 1Individual DBT sessions
- 2Emotion dysregulation and skills-based treatment
- 3DBT-informed outpatient therapy
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Diary Card Review Anger peaks 7–8/20 midweek after conflict with partner; urge to self-harm peaked at 4 without action. Used paced breathing ×3; skipped opposite action twice. Targets Quality-of-life: interpersonal conflict. No life-threatening behaviors this week. Therapy-interfering: late arrival today—addressed briefly with problem-solving. Skills Coaching Reviewed STOP and TIPP; practiced temperature + paced breathing in session. Introduced DEAR MAN outline for tonight’s boundary conversation. Risk NSSI urge max 4/5 days ago, no act; current SI denied. Safety plan reviewed; skills coach texting per protocol if urge ≥6. Plan Complete diary card daily; practice TIPP before difficult talks; try DEAR MAN once. Next session: chain analysis if urge ≥5 or conflict escalates.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.