3 - How to Write a Session Note in ReliaTrax: Step-by-Step Guide

Learn how to write and complete a session note in ReliaTrax, including step-by-step instructions for documenting individual mental health sessions, using DAP notes, and ensuring legal compliance with Colorado state and CTG policies. Remember: Client files should be updated each week with a session note, case management note, or chart note. (Explanations at end of guide). Treatment Plans should be written within the first 3 sessions and updated every 3 months.

August 3, 2025 By Eleonora

In this guide, learn how to write a session note in ReliaTrax. Accurate and timely session notes are important for client care and compliance with policies. We will cover how to document an individual session, fill in required fields, and release the note for approval within the system.

Let's get started

We will learn how to write a session note in ReliaTrax. In ReliaTrax, go to Client Search and type. Type client's name.

Go to your client's file and scroll to the bottom of file and find the treatment section and choose the appropriate Treatment template for your documentation.

When you are provided with a client referral, you will be provided with the Treatment Type information and will know if you need to document one of the following for example:

Individual session

Family session

Family with client

Family w/o client

Case Management

SCC Individual

Core Individual

Treatment Plan

...etc.

Step #2: Examples of Treatment templates available (you will not see all in your ct file... — Examples of Treatment templates available (you will not see all in your ct file...

For this training, we will complete an individual session note.

Step #3: Click "90837 Individual Session" — Click "90837 Individual Session"

Step #4: Click the "white notepad" — Click the "white notepad"

Step #5: Add Session "Date" and "Time" — Add Session "Date" and "Time"

Enter the session date and start time (indicate AM or PM).

Step #6: Click on "+green circle" to add session — Click on "+green circle" to add session

When you see the prompt Payments are 0. Add session? Click OK

Session has now been added.

Step #8: Click "Notepad w/Pencil" icon — Click "Notepad w/Pencil" icon

Step #9: Click on "Phrase List" to assist you in documentation is needed — Click on "Phrase List" to assist you in documentation is needed

Step #10: The "Phrase List" offers helpful phrase suggestions — The "Phrase List" offers helpful phrase suggestions

These are phrase lists to help you create your DAP notes.

This document is a mental health session note for my client, Test, after an individual treatment session.

Step #11: Back to writing the DAP (Session Note) — Back to writing the DAP (Session Note)

Step #12: Ensure All Info is Correct before proceeding... — Ensure All Info is Correct before proceeding...

Here is the session time and duration.

Step #13: Click on "Duration : 60 minutes change" is necessary — Click on "Duration : 60 minutes change" is necessary

Sessions are typically 60 minutes. Intake Assessments are 90 minutes.

You can change it to 30 minutes here. If you do, use the Treatment template "90832 Individual Session."

Step #14: Edit "Session Properties" and "Submit" — Edit "Session Properties" and "Submit"

Step #15: Click "Dx Code" icon to diagnosis (one time event) — Click "Dx Code" icon to diagnosis (one time event)

You will only need to enter the diagnosis code once. The only time you will need to go back to this icon is to edit a diagnosis code (Dx Code).

Step #16: Example: "F43.20 Adjustment disorder, unspecified" — Example: "F43.20 Adjustment disorder, unspecified"

If there is no diagnosis, click the green circle to add one.

Step #17: Click "+green circle" to add DX Code — Click "+green circle" to add DX Code

Step #18: Click on "search for ICD - 10 code or description" for help — Click on "search for ICD - 10 code or description" for help

Step #19: Click on "Verify POS and Dx Code" — Click on "Verify POS and Dx Code"

Verify that the place of service and diagnosis code are correct.

Step #20: Verify Date, Time, Place of Service (POS), Start/End Times & Dx Code for accuracy — Verify Date, Time, Place of Service (POS), Start/End Times & Dx Code for accuracy

This is my primary diagnosis code. This session was in-office and individual.

Step #21: Click appropriate Place of Service (POS) box — Click appropriate Place of Service (POS) box

Step #22: Click appropriate "Service Type" box — Click appropriate "Service Type" box

Step #23: Click on "Participation, Body Language / Affect" — Click on "Participation, Body Language / Affect"

My client was active, had open body language, and appeared motivated and hopeful.

Step #24: Click appropriate "Participation" and "Body Language/Affect" selections — Click appropriate "Participation" and "Body Language/Affect" selections

Step #25: Click appropriate "Mood" — Click appropriate "Mood"

Step #26: Click appropriate Stages of Change for Substance Use Disorder (SUD) cts only! — Click appropriate Stages of Change for Substance Use Disorder (SUD) cts only!

Step #27: Click appropriate "Appearance," — Click appropriate "Appearance,"

Step #28: Click on "Description of Current Issues" — Click on "Description of Current Issues"

Do not leave any sections of your session notes blank. Fill in all fields! Use N/A if a field is not applicable.

Step #29: Use the "Phrase List" if you want phrase suggestions — Use the "Phrase List" if you want phrase suggestions

Step #30: Example: Click on "Description" — Example: Click on "Description"

These are all the fields included in your description of current issues in your session notes.

Step #31: Example suggestions for DAP Descriptions... — Example suggestions for DAP Descriptions...

Step #32: Add session information here - Do note leave and fields blank — Add session information here - Do note leave and fields blank

All prompts are to help guide you to write legally compliant session notes. DO NOT LEAVE ANY FIELDS BLANK! These prompts are required to meet legal and ethical documentation criteria!

Include everything that was discussed and add client quotes.

Step #33: Goal of session should tie back to reason the client is seeing you. — Goal of session should tie back to reason the client is seeing you.

The goal of the session was to address and discuss the main issues.

Step #34: Therapeutic interventions might include: CBT, DBT, MI, SFT, Narrative, EFT, Psychodynamic, Art and Play, Person-Centered, etc. What are you using?? — Therapeutic interventions might include: CBT, DBT, MI, SFT, Narrative, EFT, Psychodynamic, Art and Play, Person-Centered, etc. What are you using??

Step #35: Add "Assessment" details — Add "Assessment" details

Step #36: Add "Plan" details — Add "Plan" details

Remember to add:

What resources did you provide to the client during the session?

What homework did you assign to the ct?

When is the next session date & time?

Is there any coordination of care?

If not applicable, please write N/A.

What will the counselor do next? (ie, reach out to caseworker, N/A, or etc.)

Step #38: Click on "Goal 1" and add details. — Click on "Goal 1" and add details.

The goals should relate to the reason they are in therapy AND Dx Code.

One to three goals is appropriate. Any can become overwhelming for cts.

What progress have you observed? Indicate any progress you observed during the session here.

Step #39: Add updated "Progress" — Add updated "Progress"

Step #40: Click "Completed Document" icon — Click "Completed Document" icon

Remember, your DAP note is not complete until you RELEASE your session note. Releasing the session note applies your digital signature, date, and time.

To meet legal documentation standards, ALL DOCUMENTATION MUST BE WRITTEN WITHIN 48 HOURS OF SESSION!

Step #41: Click "RELEASE AND APPROVE" to sign DAP-Note — Click "RELEASE AND APPROVE" to sign DAP-Note

When you release and approve the document, it will display the digital signature, date and time stamp at the bottom of the DAP-Note.

Your supervisor will review each document you sign. They will check to ensure that records are documented within 48 hours of session, Dx code is entered, the session note ties back to the treatment plan, etc.

Step #42: "Release History" shows that you "Released" the document — "Release History" shows that you "Released" the document

Chart Notes are used to document contact with clients: scheduling, res-cheduleing, coordinating transportation, updating a caseworker, etc. All ct files should be update weekly, either with session notes or chart notes. This is not a billable event and should not be used to document as Case Management.

Case Management Notes are used when you are supporting a client (other than scheduling purposes) to support their well-being, and your time and support is necessary in aiding a client's well-being. This might include meeting with caseworkers to support ct with resources or plans to improve health and well-being. This is a billable event, and the time is documented in 15-minute increments.

Treatment Plan templates can be found where Session Note templates are found. Treatment Plans should be updated every 3 months! This is a non-billable event and time/duration is 0 minutes.

I hope this was helpful. If you need further support, please reach out to Eleonora.t@live.com.