Therapy Note Example

Somatic Trauma Therapy

Client explored body-based trauma responses and practiced nervous system regulation and grounding techniques.

Therapy Progress Notes:

These therapy progress notes were written by Quill based on this specific therapy scenario.

Client Session Summary:

The therapy progress notes listed above were generated based on this summary of a client session. Quill does not record the client session. Hopefully this helps illustrate how Quill works -- a therapist would provide a summary (like this one below) after the session is over, and Quill would then generate a note like one of these examples above.

We had a 50-minute office session today. Alicia came in and right away I could see she was holding a lot of tension, shoulders up, arms crossed tight. She said she's been noticing that whenever certain topics come up, even just in passing, her body reacts before her mind does. She said quote 'I don't even have to think about the details, my chest just gets tight and I can't breathe right' unquote. She described this sense of threat that shows up in her body, tight chest, shallow breathing, sometimes her hands start shaking, even when she's not consciously thinking about the trauma.

We talked about how the body holds onto trauma, and how those sensations are the nervous system's way of trying to protect her, even when there's no actual danger in the present. I explained that we don't need to go into the details of what happened, we can work with what's happening right now in her body. We started with some gentle orienting, I asked her to look around the room and notice five things she could see, just to help her nervous system register that she's safe here in this moment. She took a few deep breaths and her shoulders started to drop a little.

Then we did some grounding work. I guided her to notice her feet on the floor, the chair supporting her, and to press her feet down gently and feel that solid contact. We went slow, checking in with her sensations as we went. Whenever she noticed her chest getting tight, we paused and just tracked it, where exactly is it, does it have a shape, does it change when you breathe into it. The goal was just to build her tolerance for those sensations without getting overwhelmed. By the end of the session, she said she felt a little less stuck in it. Her homework is to practice that orienting and grounding exercise once a day, especially if she notices those body-based cues of threat coming up. We'll meet again next week and keep building her capacity to stay present with those sensations safely.

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With only a brief session summary, Quill generates notes and other documentation for therapists. Notably, Quill does not record client sessions -- keeping those conversations private between therapist and client.

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