Many of you have asked for an example for how I set up my session notes to include the description of the Art Therapy Technique. Here is the structure that I use, and an example...
Client's Name - Type of session (individual, family, couple, phone) - Date
DATA: Stated several times that she was excited and happy to be a session. Appropriate interaction, eye contact and personal boundaries. Separated well from family, and also transitioned well back to mother after session.
ART TASK: Draw Family as animals: Father, self and grandmother are giraffes. Mother and both brothers are dinosaurs (T-Rex). Client states that the T-Rexes are stronger and sometimes scarier than the giraffes. Mother and father are near the top of the page while children are underneath - appropriate hierarchy.
Sand and glitter painting: Provided as nice connection and interaction for client and therapist. Provides role modeling of appropriate adult/child relationship and interaction.
ASSESSMENT: Client seems to be making connections/similarities between family members by making them the same animal. Client sees some family members are more aggressive.
PLAN: Continue to build trust. Continue to provide a safe place to discuss feelings, and assess for any signs of physical or sexual abuse. Provide a positive adult/child relationship.
I keep a copy/photo on computer to reference. I keep the notes fairly short, just enough to remind me of the session, in case my notes are subpoenaed into court (which has happened many times).
I always set up the notes as:
DATA: Observations and discussions
ART TECHNIQUE: State name of technique and what was said and done during.
ASSESSMENT: My own interpretations, but I always use words such as "seems to be...", "appeared like...", "may mean..."
PLAN: Future or continued goals. Possible art techniques for following session.
