Some techniques might be something you would only do once. Like a specific visualization. The routine stuff, like re-experiencing and polarity integration, you can do any number of times. But there is an advantage in knowing what you did the last time, so you don't do exactly the same, but find another angle.
The client file should document the progress of the client over time. Like, it will tell us what kind of issues she walked in with, what we did about them, and what the results were. That gives a good picture of how well we are doing something for the person, and also it shows how effective your tools are. Or, it shows you that something needs correction if we apparently aren't getting anywhere.
We don't need to have all the client's stories and experiences written down. That is not really of use. What we need is the key pieces of information, the key decision points and actions, and the observable results.
I do a one page report for each session I do. I use the Session Notes form that is attached after this. It naturally contains a line for the client's name and for my name. It has the date of the session, and also a count of how many sessions we've done. I also note down the fee that is charged for the session and how much was received. Sometimes I've made a special price arrangement with the client and I might not remember unless I look at the last session notes form. Also, sometimes she might forget her checkbook and not pay right after session like usual, so I need the form to remember that.
The main body of the Session Notes form has three columns labeled "Situation", "Process", and "Result". That is basically what I find, what I do about it, and what comes out of it.
Whatever the client's main complaint or success is when she walks in is what I'll write in the the first block right under "Situation". Maybe she will tell me that she had a great week after last session and she no longer has any problems with her boss. That is useful information, not just social talk, so we need to record that. But nothing to handle about it, that is fine.
When we find something to handle I will again put that in a Situation box. And whatever I do about it will go in the Process box next to it. Not just the successful actions, but whatever I try. It might say Dialoguing, Re-Experiencing, or whatever.
Whatever comes out of it will go in the Results box. We want the honest results, not just that the process is "Done". If it didn't really work, write that down. "Client still grumpy" or whatever. Then, in the Process box on the next line you write what you then do, and put the result in the Result box, and so forth.
On the "Next" lines at the bottom you can put any ideas you have about what to do next. You don't have to follow them or anything. It is simply if you notice during the session that something could be handled next, but we won't get to it in this session. Or, if you are following some more long-term plan, then you put the logical next step on those lines. Just as a reminder when you open the file the next time.
I put the Session Notes in sequential order in a simple manila folder. On the front and on the spine I write the client's name. On the front I also write the starting and ending date of that particular file, in the case we should ever fill up one folder.
Whenever you do a session, you simply fill in a Session Notes form right after the session, and you place it on top of the pile inside the Client File.
To keep track of what we do over the long term and whatever is left unfinished, I use a form called Open Loops. I would staple one inside the front cover, or put it in the back of the folder.
The Open Loops form, as the name says, is to note down loops that haven't been closed. That is, you start something in one session that doesn't get finished. Maybe you finish it the next session, maybe it will be some other time.
This can particularly be helpful when you get interrupted by something that has higher priority. You are working on the client's "Insecurity" issue, but then she loses her job and that becomes more pressing, and in the middle of working on that she gets sick and that gets higher priority. But as each issue gets resolved you might want to go back and finish the incomplete loops. They might or might not be hot anymore, but at least you must know that something was left incomplete. When you finish the illness you go back and check how the job is doing. And when you resolve the job issues you go back and check how the insecurity issue is. You will still always use the client's attention and interest as the main guide, but you must be able to keep track of where it has been so you can remind her.
When I open a new loop I know I can't finish in the same session I enter the date in the Open column and the subject in the Subject column. Then, whenever I work on it I would make a brief entry in the Change column. Just a date and the main action. Like, 4/27/94: Polarity. When eventually the loop is complete, the issue is resolved, I enter the date in the Close column.
The information in the Client File is not for the client to read. It is the facilitator's notes. Don't call much attention to it, but don't keep it a secret either that you are keeping notes.
The client does, legally speaking, have a right to the information you note down about her. Therefore, be prepared that she might eventually read it. Make your notes respectful and professional. The notes are not a place to natter about the client. You note down what you observed, what you did, and what happened.
If a client requests that you hand her file over to her when she terminates her sessions with you, you must comply. That rarely happens, but if it does you simply do so.