Mental health counseling record form

The mental health counseling record form is by no means a standardized administrative document used to cope with examinations. It is a core practical carrier for accepting the client's demands, anchoring the direction of intervention, and verifying the effectiveness of counseling. There is no universal filling standard for all cases. It must be flexibly adjusted based on the characteristics of the case and the style of counseling. In essence, it is more like a counselor's exclusive "clinical work notebook". Ease of use is always more important than good looks.

When I was sorting out the case files last week, I also turned to the record form of Xiaonan, a sophomore girl in high school, that I received three months ago - the upper right corner of the page she filled out for the first counseling session still had a little mark of the mango pancake cream she rubbed on it, and I scrawled the main complaint column at that time. I wrote "I dropped 30 places in the mock test rankings. I had insomnia for a week in a row. My hands shook when I mentioned the exam." There was also a small asterisk on the edge that only I could understand. The note was "The volume suddenly dropped by 20 decibels when I mentioned the look in the class teacher's eyes." If we had followed the standardized template provided by the organization at the beginning, there would have been no place to write such non-symptomatic notes. When I first entered the industry, I filled it out in a regular manner for two months. Later, I found that a lot of key information was missing, so I changed the template myself, leaving an extra third of the blank space to record such "useless details."

When I was studying with a CBT-oriented supervisor, her requirements for the record sheet were almost harsh: the three modules of "automatic thinking-intermediate beliefs-core beliefs" must be clearly divided. At the end of each counseling session, the homework completion level, cognitive adjustment range, and specific goals for the next intervention must be filled in. The severe social phobia case I took on before had a completion record of "actively greeting the cashier at the convenience store downstairs" on the record sheet for 6 consecutive times. From "dare not look up and only dared to scan the QR code" to "make eye contact for 2 seconds when saying thank you" to "actively asked if there was a discount on today's ice cream." The changes laid out on paper are more intuitive than any self-assessment scale.

But a counselor friend I know who is humanistically oriented does not agree with this logic at all. Her record sheet does not even have fixed columns. Most of the pages are blank. Each time she only writes a few words of the client that most touched her, along with a note about a small action. The last time she took the case of a 35-year-old man who had just been laid off, two sentences were written on the entire page of the record sheet: "When he said, 'It takes me half a day to even buy 20 yuan of ice cream for my daughter,' his fingers rubbed the seam of his pants until they balled up." She always said that the standardized recording module is too easy to label people. When you are busy filling in the "duration of depression" and "degree of impairment of social function", you will miss the tremor in the other person's tone and miss the entrance to truly catch the emotion.

In fact, there has never been an ongoing debate in the industry about this set of records. There are even extreme views that as long as the consultant's memory is good enough, there is no need to write a record form at all, which is a waste of time and can easily lead to distraction. I have stepped into this trap myself: the last time a visitor was talking about her experience of being bullied in junior high school, I was busy filling in the standardized columns such as "Inducement" and "Duration of Symptoms". When I looked up, I found that she had been silent for three minutes with her sleeves clenched. After that time, I changed my habit. During tutoring, I only wrote two keywords on the note, and I immediately completed the record sheet within 10 minutes after the visitor left. I never immersed myself in writing when the other person opened up.

It's interesting to say that the record sheets I've seen really come in all shapes and sizes: A colleague who works as a child tutor had a record sheet filled with graffiti drawn by visiting children.； There is a senior who does post-disaster psychological intervention, and the corners of the record sheet are even stained with mud from the disaster area. ； There are also young counselors who are new to the industry who will secretly write down their emotional fluctuations at the time in the corner of the record sheet, remarking, "I almost cried when he said he was abandoned by his parents just now. I need to be more steady next time."

I was having dinner with colleagues last week and we were talking about this matter. We laughed and said that many newcomers are always worried about whether the record form is filled out in a standard enough way, and whether they will be scolded by the supervisor. In fact, it is completely unnecessary - this thing is originally for the counseling itself. It can help you remember the unique small details of the client, and can help you accurately catch the other person’s unspoken emotions in the next counseling session. It is more meaningful than conforming to any unified standards. After all, we are doing people's work, not filling in the blanks, right?