Culture and writing
Marriage and family therapist interview clients and reviews records. Depending on the situation, other therapists, counselors, doctors, or social workers are consulted. They write evaluations of parents and children for use by courts deciding divorce and custody cases, testifying in court if necessary. In their notes they include, intake/assessment, the diagnosis, goals/objectives, service plan, Data Assessment Plan (DAP), progress notes and discharge plan. Progress notes are a description of major events or topics discussed during the session and specific interventions. MFTs try to avoid any words that suggest moral judgments such as "good" or "bad". They also avoid tentative language which includes "may" or "seems".
Progress notes include:
An admission note is written following the initial assessment session with the patient. In the note, the therapist presents the problem and records what they observed. The note also contains acknowledgement of informed consent and patient rights discussions as well as acknowledgement that a bio psychosocial assessment was performed. The next note that a MFT writes is a discharge note. This contains a summary of the treatment that was provided to the patient, the level of progress achieved according to the current treatment plan, reason for termination, and recovery plan/recommendations.
To view a sample of a sample letter written by a marriage and family therapist for
pre-marriage counseling click here.
Progress notes include:
- Diagnosis
- Functional status
- Symptoms
- Prognosis
- Progress to date
An admission note is written following the initial assessment session with the patient. In the note, the therapist presents the problem and records what they observed. The note also contains acknowledgement of informed consent and patient rights discussions as well as acknowledgement that a bio psychosocial assessment was performed. The next note that a MFT writes is a discharge note. This contains a summary of the treatment that was provided to the patient, the level of progress achieved according to the current treatment plan, reason for termination, and recovery plan/recommendations.
To view a sample of a sample letter written by a marriage and family therapist for
pre-marriage counseling click here.