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Date: 2026-04-24 Time: 18:00–19:30 (90 min, 90853 group) Diagnosis: F10.20 Alcohol Use Disorder, Uncomplicated Patient: K.R., session #8 of 16-week IOP B: Behavior Patient arrived on time, engaged with cohort, mood euthymic. Reports 12 days continuous sobriety. AUDIT-PC at intake = 9 (down from 14 at IOP start). Self-disclosed during the session: "this is the longest I've gone without drinking since college." Mild discomfort discussing relapse triggers; deflected initially with humor. I: Intervention Group leader (clinician) facilitated a CBT-based relapse-prevention exercise: identifying high-risk situations and pairing each with a specific coping plan. Reflected back patient's deflection with empathic confrontation ("I noticed humor came up when we got to the trigger list"). Provided psychoeducation on HALT (Hungry/Angry/Lonely/Tired) trigger framework. R: Response Patient softened after the empathic confrontation, named two specific high-risk situations (Friday after-work drinks with colleagues; conflict with spouse). Generated three coping strategies for each, with the clinician's prompting. Verbal commitment to call sponsor before either situation in the next 7 days. Affective tone shifted from defensive to engaged. P: Plan Continue weekly IOP × 8 more weeks. Re-administer AUDIT-PC at session 12. Patient to call sponsor at minimum 1×/week and before any identified high-risk situation. Reinforce HALT framework in next individual check-in. Discussed naltrexone option with patient. Referring to outpatient psychiatrist for evaluation. CPT: 90853 + 96127×1 (AUDIT-PC)

Date: ____ Time: ____ – ____ (___ min, CPT ____) Diagnosis: ____ (ICD-11) Patient: ____, session #___ of ___ B: Behavior [Patient affect, mood, engagement, body language, statements. Scale scores: PHQ-9 ___, GAD-7 ___, AUDIT ___ (whichever administered). Behavioral observations.] I: Intervention [Specific therapeutic interventions deployed. Techniques used (CBT, DBT, MI, psychoeducation, exposure, safety planning). Scale administration as part of intervention if applicable.] R: Response [Patient response to each intervention: affective shift, insight, commitment, resistance. How well did the intervention land?] P: Plan [Next-session interventions, frequency, referrals, scales to re-administer, homework, safety planning.] CPT: ____ + 96127×__ (scales administered)