Summary
DBT individual therapy sessions follow a structured agenda — target hierarchy review, diary card, chain analysis, skills work. A defensible DBT session note maps onto that agenda. The structure also supports treatment fidelity if the practitioner is in DBT consultation team supervision.
DBT target hierarchy
Linehan's framework prioritises session content as:
- Life-threatening behaviours (suicide, self-harm).
- Therapy-interfering behaviours (lateness, non-completion of homework, missed sessions).
- Quality-of-life-interfering behaviours (substance use, eating issues, employment instability).
- Skills acquisition.
A session note should record where in the hierarchy the session focussed and why.
Standard session-note structure
- Date, duration, mode (individual, telehealth, phone coaching).
- Diary card review — which target behaviours occurred, frequency, intensity, urges.
- Target identified for the session — and where it sits in the hierarchy.
- Behavioural chain analysis (if conducted) — vulnerability factors, prompting event, links (thoughts, feelings, actions, sensations), problem behaviour, consequences. Document the analysis in a structured way; the chain itself is the clinical artefact.
- Solution analysis — alternative responses identified at each link of the chain.
- Skills coaching delivered — which skill, why, how the client engaged.
- Therapy-interfering behaviours noted and addressed.
- Homework agreed for between sessions.
- Risk status — current SI/SH urges, safety plan in place.
- Plan for next session.
Diary card retention
Diary cards are a clinical artefact. Practitioners should retain copies (or digital images) in the file. A session note that references "diary card reviewed" without the card itself in the record cannot be audited later.
Phone coaching call documentation
DBT phone coaching calls are part of treatment and need their own brief notes:
- Date, time, duration.
- Crisis or skills-coaching nature.
- Skills suggested.
- Outcome.
Consultation team
DBT practitioners working in fidelity programs attend weekly consultation team meetings. Those meetings have their own confidential record but the *fact* of consultation should appear in the client file.
Related reading
How we review this guide
Library guides reference original Australian source authorities — not secondary commentary — and are updated when source material changes. Each guide cites the regulator, item descriptor, or governing standard it draws from so you can verify it directly.
- Sources checked
- • Original Australian source authorities and peer-reviewed guidance
- Review cadence
- Reviewed annually and whenever a cited source authority publishes a material change. Last reviewed .
- Not advice
- Reference content for Australian practitioners and education staff. Not legal, clinical, or billing advice — verify against your governing body and current source documents.
Keywords: dbt session note documentation, dialectical behaviour therapy notes, dbt diary card documentation, dbt chain analysis note, dbt skills coaching documentation
Keep reading
More on guides
Free, evergreen reference for Australian practitioners and school staff.
BrowseTry a free tool
Free assessment calculators
Score 33+ standardised assessments online. Download a PDF report. No account needed.
Open the toolsTry Grounded Scribe
Spend less time on documentation
AI drafts compliant clinical notes from your dictation or recording. Free tier — no card.
Start freeWas this article helpful?
Related Articles
Continue exploring related topics
Paediatric ADHD Diagnostic Reports: A Structure for Australian Clinicians
ADHD diagnostic reports for paediatricians and psychologists must satisfy DSM-5-TR criteria, exclude alternative explanations, and provide enough detail to support school adjustments and (where applicable) PBS prescribing. This guide outlines a defensible report structure.
Developmental Coordination Disorder Assessment Reports: A Documentation Guide
DCD diagnostic reports prepared by occupational therapists and paediatricians must satisfy DSM-5-TR criteria and provide enough functional detail to support school adjustments and (where applicable) NDIS funding. This guide outlines the report structure.
Childhood Apraxia of Speech Assessment Reports: A Speech Pathology Guide
Childhood Apraxia of Speech (CAS) diagnostic reports must reference the three core features identified by ASHA, document the assessment battery, and provide enough detail for the report to support school adjustments and NDIS funding requests.