Appearance and Behavior

Use this section for simple, objective language describing how the client presents during session. Documentation should stay descriptive and avoid judgmental wording.

Appearance

Common appearance descriptors may include:

• Appropriate
• Neat
• Disheveled
• Inappropriate
• Malodorous / poor hygiene
• Unkempt
• Other clinically relevant appearance observations

Behavior

Common behavior descriptors may include:

• Cooperative
• Engaged
• Guarded
• Agitated or aggressive
• Passive
• Fearful
• Impulsive
• Dramatic
• Apprehensive
• Withdrawn
• Other clinically relevant behavior observations

Example Documentation Language

• Client presented with appropriate appearance and cooperative behavior throughout session.
• Patient appeared neat and engaged appropriately in the therapeutic process.
• Client presented as guarded and somewhat withdrawn, though remained able to participate in session.
• Patient appeared disheveled and demonstrated reduced engagement during session.
• Client presented with agitation and required support with emotional regulation during session.