BIRP Note

Client presented as [observations: appearance, mood, affect]. Client reported [symptoms/concerns in client's own words]. Mental status: [relevant findings]. Behaviors observed in session: [specific, objective descriptions].

Therapist utilized [specific technique/modality] to address [treatment plan goal]. Provided [psychoeducation/skills training]. Explored [themes or patterns] using [approach].

Client responded by [engagement/reaction to interventions]. Client demonstrated [skill use or insight gained]. Progress toward goal: [specific, measurable progress]. Barriers noted: [if any].

Continue [frequency] sessions focusing on [next focus area]. Homework: [assigned task]. Next session: [date/planned focus]. Referrals or care coordination: [if applicable].

Client arrived on time, casually dressed with appropriate grooming. Mood was reported as "flat and unmotivated," affect was constricted. Client reported sleeping 10+ hours daily and missing two work shifts this week. Client made limited eye contact early in session, which improved when discussing his daughter.

Therapist used behavioral activation to address the treatment goal of increasing daily structure. Collaboratively built a graded activity schedule starting with two low-effort activities per day. Provided psychoeducation on the link between activity withdrawal and depressed mood.

Client engaged actively in building the schedule and identified walking his daughter to school as a valued, achievable daily activity. Client demonstrated understanding of the activity-mood cycle, stating "the less I do, the worse I feel, and then I do even less." Progress toward goal: client completed one of three scheduled activities from last week, up from zero.

Continue weekly sessions focusing on behavioral activation and sleep routine. Homework: complete activity schedule with daily mood ratings. Next session: review schedule adherence and introduce thought records. No referrals needed at this time.