Documentation Templates for Every Visit

Structured templates that help you capture clinical notes quickly and clearly.

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Initial / Follow-up / Consultation]

S – Subjective

Patient’s own words and reported experience.

Chief Complaint (CC): [Patient’s main concern, in their own words]

History of Present Illness (HPI):

  • Onset: [When symptoms started]

  • Duration: [How long symptoms have persisted]

  • Triggers: [Situations or events that worsen symptoms]

  • Relievers: [What improves symptoms, if anything]

  • Impact: [Effect on daily life, relationships, work, school, sleep, appetite]

Psychiatric History: [Prior diagnoses, therapy, hospitalizations, medications, response to treatment]
Medical History: [Relevant medical conditions, surgeries, allergies, chronic illnesses]
Family History: [Psychiatric, substance use, or medical conditions in family]

Social History:

  • Living Situation: [Who patient lives with, safety, stability]

  • Occupation/School: [Role, stressors, performance impact]

  • Substance Use: [Alcohol, cannabis, stimulants, opioids, tobacco; frequency and last use]

  • Support System: [Family, friends, community, faith, groups]

O – Objective

Clinician’s observations.

Mental Status Examination (MSE):

  • Appearance: [Grooming, attire, hygiene]

  • Behavior: [Cooperative, guarded, agitated, withdrawn]

  • Speech: [Rate, volume, tone, fluency]

  • Mood: [Patient-reported mood]

  • Affect: [Observed affect, range, congruence]

  • Thought Process: [Linear, tangential, circumstantial, disorganized]

  • Thought Content: [Obsessions, delusions, guilt, paranoia, preoccupations]

  • Perception: [Hallucinations, dissociation, depersonalization]

  • Insight: [Good, fair, poor]

  • Judgment: [Intact, impaired]

  • Cognition: [Orientation, attention, memory, concentration]

Vital Signs (if applicable): [BP, HR, RR, Temp, weight; include only if relevant]

A – Assessment

Diagnosis: [Primary and secondary diagnoses; DSM-5 codes if applicable]
Clinical Impression: [Severity, contributing factors, functional impact]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan, intent, means, timeframe if yes]

  • Homicidal Ideation: [Yes/No; plan, intent, means if yes]

  • Risk Level: [Low / Moderate / High; rationale]

Response to Treatment: [If follow-up, progress since last session and examples]

P – Plan

Therapeutic Interventions: [CBT, DBT, supportive therapy, psychoeducation, skills practice]
Medications: [Medication name, dose, route, frequency, changes, counseling]
Lifestyle Recommendations: [Sleep hygiene, exercise, nutrition, stress reduction]
Referrals: [Therapy, psychiatry, labs, specialist, social work]
Follow-Up: [Next appointment date or timeframe]
Crisis Plan: [Emergency contacts, 988/ER instructions, safety steps]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

SOAP

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Initial / Follow-up / Consultation]

S – Subjective

Patient’s own words and reported experience.

Chief Complaint (CC): [Patient’s main concern, in their own words]

History of Present Illness (HPI):

  • Onset: [When symptoms started]

  • Duration: [How long symptoms have persisted]

  • Triggers: [Situations or events that worsen symptoms]

  • Relievers: [What improves symptoms, if anything]

  • Impact: [Effect on daily life, relationships, work, school, sleep, appetite]

Psychiatric History: [Prior diagnoses, therapy, hospitalizations, medications, response to treatment]
Medical History: [Relevant medical conditions, surgeries, allergies, chronic illnesses]
Family History: [Psychiatric, substance use, or medical conditions in family]

Social History:

  • Living Situation: [Who patient lives with, safety, stability]

  • Occupation/School: [Role, stressors, performance impact]

  • Substance Use: [Alcohol, cannabis, stimulants, opioids, tobacco; frequency and last use]

  • Support System: [Family, friends, community, faith, groups]

O – Objective

Clinician’s observations.

Mental Status Examination (MSE):

  • Appearance: [Grooming, attire, hygiene]

  • Behavior: [Cooperative, guarded, agitated, withdrawn]

  • Speech: [Rate, volume, tone, fluency]

  • Mood: [Patient-reported mood]

  • Affect: [Observed affect, range, congruence]

  • Thought Process: [Linear, tangential, circumstantial, disorganized]

  • Thought Content: [Obsessions, delusions, guilt, paranoia, preoccupations]

  • Perception: [Hallucinations, dissociation, depersonalization]

  • Insight: [Good, fair, poor]

  • Judgment: [Intact, impaired]

  • Cognition: [Orientation, attention, memory, concentration]

Vital Signs (if applicable): [BP, HR, RR, Temp, weight; include only if relevant]

A – Assessment

Diagnosis: [Primary and secondary diagnoses; DSM-5 codes if applicable]
Clinical Impression: [Severity, contributing factors, functional impact]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan, intent, means, timeframe if yes]

  • Homicidal Ideation: [Yes/No; plan, intent, means if yes]

  • Risk Level: [Low / Moderate / High; rationale]

Response to Treatment: [If follow-up, progress since last session and examples]

P – Plan

Therapeutic Interventions: [CBT, DBT, supportive therapy, psychoeducation, skills practice]
Medications: [Medication name, dose, route, frequency, changes, counseling]
Lifestyle Recommendations: [Sleep hygiene, exercise, nutrition, stress reduction]
Referrals: [Therapy, psychiatry, labs, specialist, social work]
Follow-Up: [Next appointment date or timeframe]
Crisis Plan: [Emergency contacts, 988/ER instructions, safety steps]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

SOAP

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Initial / Follow-up / Consultation]

S – Subjective

Patient’s own words and reported experience.

Chief Complaint (CC): [Patient’s main concern, in their own words]

History of Present Illness (HPI):

  • Onset: [When symptoms started]

  • Duration: [How long symptoms have persisted]

  • Triggers: [Situations or events that worsen symptoms]

  • Relievers: [What improves symptoms, if anything]

  • Impact: [Effect on daily life, relationships, work, school, sleep, appetite]

Psychiatric History: [Prior diagnoses, therapy, hospitalizations, medications, response to treatment]
Medical History: [Relevant medical conditions, surgeries, allergies, chronic illnesses]
Family History: [Psychiatric, substance use, or medical conditions in family]

Social History:

  • Living Situation: [Who patient lives with, safety, stability]

  • Occupation/School: [Role, stressors, performance impact]

  • Substance Use: [Alcohol, cannabis, stimulants, opioids, tobacco; frequency and last use]

  • Support System: [Family, friends, community, faith, groups]

O – Objective

Clinician’s observations.

Mental Status Examination (MSE):

  • Appearance: [Grooming, attire, hygiene]

  • Behavior: [Cooperative, guarded, agitated, withdrawn]

  • Speech: [Rate, volume, tone, fluency]

  • Mood: [Patient-reported mood]

  • Affect: [Observed affect, range, congruence]

  • Thought Process: [Linear, tangential, circumstantial, disorganized]

  • Thought Content: [Obsessions, delusions, guilt, paranoia, preoccupations]

  • Perception: [Hallucinations, dissociation, depersonalization]

  • Insight: [Good, fair, poor]

  • Judgment: [Intact, impaired]

  • Cognition: [Orientation, attention, memory, concentration]

Vital Signs (if applicable): [BP, HR, RR, Temp, weight; include only if relevant]

A – Assessment

Diagnosis: [Primary and secondary diagnoses; DSM-5 codes if applicable]
Clinical Impression: [Severity, contributing factors, functional impact]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan, intent, means, timeframe if yes]

  • Homicidal Ideation: [Yes/No; plan, intent, means if yes]

  • Risk Level: [Low / Moderate / High; rationale]

Response to Treatment: [If follow-up, progress since last session and examples]

P – Plan

Therapeutic Interventions: [CBT, DBT, supportive therapy, psychoeducation, skills practice]
Medications: [Medication name, dose, route, frequency, changes, counseling]
Lifestyle Recommendations: [Sleep hygiene, exercise, nutrition, stress reduction]
Referrals: [Therapy, psychiatry, labs, specialist, social work]
Follow-Up: [Next appointment date or timeframe]
Crisis Plan: [Emergency contacts, 988/ER instructions, safety steps]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

SOAP

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Initial / Follow-up]

D – Data

Client Statements: [Key quotes or paraphrased concerns in patient’s words]
Reported Symptoms: [Mood, anxiety, sleep, appetite, energy, concentration; frequency/severity]
Session Content: [Main topics discussed, recent events, stressors, triggers]
Clinician Observations: [Appearance, behavior, affect, engagement, speech, notable signs]

A – Assessment

Clinical Impression: [Interpretation of symptoms, patterns, contributing factors]
Progress Toward Goals: [Improving/stable/worsening with examples]
Response to Interventions: [What helped, what did not, engagement level]
Risk Review: [SI/HI present or denied; protective factors; risk level]

P – Plan

Interventions: [Techniques used today and planned next steps]
Assignments: [Homework, coping skills, journaling, practice tasks]
Referrals/Coordination: [Care coordination, referrals, resources provided]
Follow-Up: [Next visit date or timeframe; monitoring plan]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

DAP

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Initial / Follow-up]

D – Data

Client Statements: [Key quotes or paraphrased concerns in patient’s words]
Reported Symptoms: [Mood, anxiety, sleep, appetite, energy, concentration; frequency/severity]
Session Content: [Main topics discussed, recent events, stressors, triggers]
Clinician Observations: [Appearance, behavior, affect, engagement, speech, notable signs]

A – Assessment

Clinical Impression: [Interpretation of symptoms, patterns, contributing factors]
Progress Toward Goals: [Improving/stable/worsening with examples]
Response to Interventions: [What helped, what did not, engagement level]
Risk Review: [SI/HI present or denied; protective factors; risk level]

P – Plan

Interventions: [Techniques used today and planned next steps]
Assignments: [Homework, coping skills, journaling, practice tasks]
Referrals/Coordination: [Care coordination, referrals, resources provided]
Follow-Up: [Next visit date or timeframe; monitoring plan]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

DAP

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Initial / Follow-up]

D – Data

Client Statements: [Key quotes or paraphrased concerns in patient’s words]
Reported Symptoms: [Mood, anxiety, sleep, appetite, energy, concentration; frequency/severity]
Session Content: [Main topics discussed, recent events, stressors, triggers]
Clinician Observations: [Appearance, behavior, affect, engagement, speech, notable signs]

A – Assessment

Clinical Impression: [Interpretation of symptoms, patterns, contributing factors]
Progress Toward Goals: [Improving/stable/worsening with examples]
Response to Interventions: [What helped, what did not, engagement level]
Risk Review: [SI/HI present or denied; protective factors; risk level]

P – Plan

Interventions: [Techniques used today and planned next steps]
Assignments: [Homework, coping skills, journaling, practice tasks]
Referrals/Coordination: [Care coordination, referrals, resources provided]
Follow-Up: [Next visit date or timeframe; monitoring plan]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

DAP

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Session Type: [In-person / Telehealth]

B – Behavior

Presenting Concerns: [Primary issues reported today]
Mood/Affect: [Mood described and affect observed]
Behavioral Indicators: [Eye contact, psychomotor activity, agitation, withdrawal]
Functional Impact: [Work/school/home impact, relationships, daily functioning]

I – Intervention

Techniques Used: [CBT, DBT, MI, grounding, supportive counseling, psychoeducation]
Topics Addressed: [Themes discussed and clinical focus]
Skills Practiced: [Breathing, cognitive reframing, behavioral activation, etc.]
Resources Provided: [Handouts, referrals, crisis resources, community support]

R – Response

Engagement: [Receptive, neutral, resistant; examples]
Client Feedback: [What the patient said was helpful or challenging]
Insight: [New realizations, motivation, readiness to change]
Observed Change: [Any shift in affect, distress level, clarity]

P – Plan

Next Steps: [Plan for next session and treatment direction]
Homework: [Assigned tasks, practice plan, frequency]
Referrals: [If applicable]
Follow-Up: [Next appointment date/timeframe]
Safety Plan: [If needed, steps and contacts]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

BIRP

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Session Type: [In-person / Telehealth]

B – Behavior

Presenting Concerns: [Primary issues reported today]
Mood/Affect: [Mood described and affect observed]
Behavioral Indicators: [Eye contact, psychomotor activity, agitation, withdrawal]
Functional Impact: [Work/school/home impact, relationships, daily functioning]

I – Intervention

Techniques Used: [CBT, DBT, MI, grounding, supportive counseling, psychoeducation]
Topics Addressed: [Themes discussed and clinical focus]
Skills Practiced: [Breathing, cognitive reframing, behavioral activation, etc.]
Resources Provided: [Handouts, referrals, crisis resources, community support]

R – Response

Engagement: [Receptive, neutral, resistant; examples]
Client Feedback: [What the patient said was helpful or challenging]
Insight: [New realizations, motivation, readiness to change]
Observed Change: [Any shift in affect, distress level, clarity]

P – Plan

Next Steps: [Plan for next session and treatment direction]
Homework: [Assigned tasks, practice plan, frequency]
Referrals: [If applicable]
Follow-Up: [Next appointment date/timeframe]
Safety Plan: [If needed, steps and contacts]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

BIRP

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Session Type: [In-person / Telehealth]

B – Behavior

Presenting Concerns: [Primary issues reported today]
Mood/Affect: [Mood described and affect observed]
Behavioral Indicators: [Eye contact, psychomotor activity, agitation, withdrawal]
Functional Impact: [Work/school/home impact, relationships, daily functioning]

I – Intervention

Techniques Used: [CBT, DBT, MI, grounding, supportive counseling, psychoeducation]
Topics Addressed: [Themes discussed and clinical focus]
Skills Practiced: [Breathing, cognitive reframing, behavioral activation, etc.]
Resources Provided: [Handouts, referrals, crisis resources, community support]

R – Response

Engagement: [Receptive, neutral, resistant; examples]
Client Feedback: [What the patient said was helpful or challenging]
Insight: [New realizations, motivation, readiness to change]
Observed Change: [Any shift in affect, distress level, clarity]

P – Plan

Next Steps: [Plan for next session and treatment direction]
Homework: [Assigned tasks, practice plan, frequency]
Referrals: [If applicable]
Follow-Up: [Next appointment date/timeframe]
Safety Plan: [If needed, steps and contacts]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

BIRP

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Intake: [MM/DD/YYYY]
Visit Type: [Initial / Consultation]

Presenting Problem: [Reason for visit and what prompted care now]
Chief Concerns: [Top 1–3 concerns in patient’s words]
Symptom Overview: [Key symptoms, frequency, severity, duration]

History of Present Illness (HPI):

  • Onset: [When it began]

  • Course: [Worsening, improving, episodic]

  • Triggers: [Stressors, events]

  • Impact: [Functioning at work/school/home, relationships]

Psychiatric History:

  • Prior Diagnoses: [If any]

  • Prior Treatment: [Therapy types, medications tried, response]

  • Hospitalizations: [Dates/reasons if applicable]

Medical History: [Relevant conditions, surgeries, allergies, current non-psych meds]
Family History: [Mental health, substance use, suicide history, major medical issues]

Social History:

  • Living Situation: [Household composition, stability, safety]

  • Occupation/School: [Role, stressors, attendance/performance]

  • Substance Use: [Type, frequency, last use, prior treatment]

  • Legal/Trauma History: [If relevant and appropriate]

  • Support System: [Primary supports and availability]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan/intent/means if yes]

  • Homicidal Ideation: [Yes/No; details if yes]

  • Self-Harm: [History, current urges]

  • Protective Factors: [Supports, coping skills, reasons for living]

  • Risk Level: [Low / Moderate / High; rationale]

Initial Impression: [Summary of presentation and key drivers]
Provisional Diagnosis: [Working diagnosis; DSM-5 code if applicable]
Treatment Recommendations:

  • Therapy Plan: [Frequency and approach]

  • Medication Plan: [If applicable]

  • Referrals: [As needed]

  • Follow-Up: [Timeframe]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Intake Assessment

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Intake: [MM/DD/YYYY]
Visit Type: [Initial / Consultation]

Presenting Problem: [Reason for visit and what prompted care now]
Chief Concerns: [Top 1–3 concerns in patient’s words]
Symptom Overview: [Key symptoms, frequency, severity, duration]

History of Present Illness (HPI):

  • Onset: [When it began]

  • Course: [Worsening, improving, episodic]

  • Triggers: [Stressors, events]

  • Impact: [Functioning at work/school/home, relationships]

Psychiatric History:

  • Prior Diagnoses: [If any]

  • Prior Treatment: [Therapy types, medications tried, response]

  • Hospitalizations: [Dates/reasons if applicable]

Medical History: [Relevant conditions, surgeries, allergies, current non-psych meds]
Family History: [Mental health, substance use, suicide history, major medical issues]

Social History:

  • Living Situation: [Household composition, stability, safety]

  • Occupation/School: [Role, stressors, attendance/performance]

  • Substance Use: [Type, frequency, last use, prior treatment]

  • Legal/Trauma History: [If relevant and appropriate]

  • Support System: [Primary supports and availability]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan/intent/means if yes]

  • Homicidal Ideation: [Yes/No; details if yes]

  • Self-Harm: [History, current urges]

  • Protective Factors: [Supports, coping skills, reasons for living]

  • Risk Level: [Low / Moderate / High; rationale]

Initial Impression: [Summary of presentation and key drivers]
Provisional Diagnosis: [Working diagnosis; DSM-5 code if applicable]
Treatment Recommendations:

  • Therapy Plan: [Frequency and approach]

  • Medication Plan: [If applicable]

  • Referrals: [As needed]

  • Follow-Up: [Timeframe]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Intake Assessment

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Intake: [MM/DD/YYYY]
Visit Type: [Initial / Consultation]

Presenting Problem: [Reason for visit and what prompted care now]
Chief Concerns: [Top 1–3 concerns in patient’s words]
Symptom Overview: [Key symptoms, frequency, severity, duration]

History of Present Illness (HPI):

  • Onset: [When it began]

  • Course: [Worsening, improving, episodic]

  • Triggers: [Stressors, events]

  • Impact: [Functioning at work/school/home, relationships]

Psychiatric History:

  • Prior Diagnoses: [If any]

  • Prior Treatment: [Therapy types, medications tried, response]

  • Hospitalizations: [Dates/reasons if applicable]

Medical History: [Relevant conditions, surgeries, allergies, current non-psych meds]
Family History: [Mental health, substance use, suicide history, major medical issues]

Social History:

  • Living Situation: [Household composition, stability, safety]

  • Occupation/School: [Role, stressors, attendance/performance]

  • Substance Use: [Type, frequency, last use, prior treatment]

  • Legal/Trauma History: [If relevant and appropriate]

  • Support System: [Primary supports and availability]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan/intent/means if yes]

  • Homicidal Ideation: [Yes/No; details if yes]

  • Self-Harm: [History, current urges]

  • Protective Factors: [Supports, coping skills, reasons for living]

  • Risk Level: [Low / Moderate / High; rationale]

Initial Impression: [Summary of presentation and key drivers]
Provisional Diagnosis: [Working diagnosis; DSM-5 code if applicable]
Treatment Recommendations:

  • Therapy Plan: [Frequency and approach]

  • Medication Plan: [If applicable]

  • Referrals: [As needed]

  • Follow-Up: [Timeframe]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Intake Assessment

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Follow-up]

Interval History: [What has changed since the last visit]
Current Symptoms: [Improved/worsened/stable; examples and severity]
Functional Status: [Work/school/home functioning and relationships]

Interventions Provided:

  • Therapeutic Techniques: [Specific methods used]

  • Education: [Topics covered and patient understanding]

  • Care Coordination: [Calls, messages, updates with other providers if applicable]

Patient Response:

  • Engagement: [Active/passive/resistant]

  • Progress Toward Goals: [Concrete progress and barriers]

  • Risk Review: [SI/HI denied or present; risk level]

Plan:

  • Adjustments: [Changes to therapy plan, meds, or goals]

  • Homework: [Assignments and frequency]

  • Follow-Up: [Next visit timeframe]

  • Referrals: [If applicable]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Progress Note

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Follow-up]

Interval History: [What has changed since the last visit]
Current Symptoms: [Improved/worsened/stable; examples and severity]
Functional Status: [Work/school/home functioning and relationships]

Interventions Provided:

  • Therapeutic Techniques: [Specific methods used]

  • Education: [Topics covered and patient understanding]

  • Care Coordination: [Calls, messages, updates with other providers if applicable]

Patient Response:

  • Engagement: [Active/passive/resistant]

  • Progress Toward Goals: [Concrete progress and barriers]

  • Risk Review: [SI/HI denied or present; risk level]

Plan:

  • Adjustments: [Changes to therapy plan, meds, or goals]

  • Homework: [Assignments and frequency]

  • Follow-Up: [Next visit timeframe]

  • Referrals: [If applicable]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Progress Note

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Follow-up]

Interval History: [What has changed since the last visit]
Current Symptoms: [Improved/worsened/stable; examples and severity]
Functional Status: [Work/school/home functioning and relationships]

Interventions Provided:

  • Therapeutic Techniques: [Specific methods used]

  • Education: [Topics covered and patient understanding]

  • Care Coordination: [Calls, messages, updates with other providers if applicable]

Patient Response:

  • Engagement: [Active/passive/resistant]

  • Progress Toward Goals: [Concrete progress and barriers]

  • Risk Review: [SI/HI denied or present; risk level]

Plan:

  • Adjustments: [Changes to therapy plan, meds, or goals]

  • Homework: [Assignments and frequency]

  • Follow-Up: [Next visit timeframe]

  • Referrals: [If applicable]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Progress Note

Template Sample

Patient Information
Name: [Patient Name]
Date of Evaluation: [MM/DD/YYYY]
Visit Type: [Initial Psychiatric Evaluation]

Chief Complaint (CC): [Patient’s stated reason for evaluation]

History of Present Illness (HPI):

  • Onset: [When symptoms began]

  • Course: [Trajectory over time]

  • Severity: [Impact on functioning]

  • Triggers/Relievers: [What worsens/helps]

  • Associated Symptoms: [Sleep, appetite, energy, concentration]

Psychiatric History:

  • Diagnoses: [Prior diagnoses]

  • Medications: [Trials, response, side effects]

  • Therapy: [Type, duration, response]

  • Hospitalizations: [Dates/reasons]

Medical History: [Medical conditions, surgeries, allergies]
Substance Use History: [Alcohol/drugs/tobacco; frequency, last use, treatment history]
Family History: [Psychiatric/substance use/suicide history]
Social History: [Living situation, work/school, supports, stressors]

Mental Status Examination (MSE):

  • Appearance: [Details]

  • Behavior: [Details]

  • Speech: [Details]

  • Mood: [Details]

  • Affect: [Details]

  • Thought Process: [Details]

  • Thought Content: [Details]

  • Perception: [Details]

  • Insight: [Details]

  • Judgment: [Details]

  • Cognition: [Details]

Assessment: [Summary of findings and key differentials if relevant]
Diagnosis: [DSM-5 diagnoses and codes if applicable]

Plan:

  • Medications: [Start/continue/change; counseling provided]

  • Therapy: [Recommended approach and frequency]

  • Referrals/Labs: [If needed]

  • Follow-Up: [Timeframe]

  • Safety Plan: [If needed]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Psychiatric Evaluation

Template Sample

Patient Information
Name: [Patient Name]
Date of Evaluation: [MM/DD/YYYY]
Visit Type: [Initial Psychiatric Evaluation]

Chief Complaint (CC): [Patient’s stated reason for evaluation]

History of Present Illness (HPI):

  • Onset: [When symptoms began]

  • Course: [Trajectory over time]

  • Severity: [Impact on functioning]

  • Triggers/Relievers: [What worsens/helps]

  • Associated Symptoms: [Sleep, appetite, energy, concentration]

Psychiatric History:

  • Diagnoses: [Prior diagnoses]

  • Medications: [Trials, response, side effects]

  • Therapy: [Type, duration, response]

  • Hospitalizations: [Dates/reasons]

Medical History: [Medical conditions, surgeries, allergies]
Substance Use History: [Alcohol/drugs/tobacco; frequency, last use, treatment history]
Family History: [Psychiatric/substance use/suicide history]
Social History: [Living situation, work/school, supports, stressors]

Mental Status Examination (MSE):

  • Appearance: [Details]

  • Behavior: [Details]

  • Speech: [Details]

  • Mood: [Details]

  • Affect: [Details]

  • Thought Process: [Details]

  • Thought Content: [Details]

  • Perception: [Details]

  • Insight: [Details]

  • Judgment: [Details]

  • Cognition: [Details]

Assessment: [Summary of findings and key differentials if relevant]
Diagnosis: [DSM-5 diagnoses and codes if applicable]

Plan:

  • Medications: [Start/continue/change; counseling provided]

  • Therapy: [Recommended approach and frequency]

  • Referrals/Labs: [If needed]

  • Follow-Up: [Timeframe]

  • Safety Plan: [If needed]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Psychiatric Evaluation

Template Sample

Patient Information
Name: [Patient Name]
Date of Evaluation: [MM/DD/YYYY]
Visit Type: [Initial Psychiatric Evaluation]

Chief Complaint (CC): [Patient’s stated reason for evaluation]

History of Present Illness (HPI):

  • Onset: [When symptoms began]

  • Course: [Trajectory over time]

  • Severity: [Impact on functioning]

  • Triggers/Relievers: [What worsens/helps]

  • Associated Symptoms: [Sleep, appetite, energy, concentration]

Psychiatric History:

  • Diagnoses: [Prior diagnoses]

  • Medications: [Trials, response, side effects]

  • Therapy: [Type, duration, response]

  • Hospitalizations: [Dates/reasons]

Medical History: [Medical conditions, surgeries, allergies]
Substance Use History: [Alcohol/drugs/tobacco; frequency, last use, treatment history]
Family History: [Psychiatric/substance use/suicide history]
Social History: [Living situation, work/school, supports, stressors]

Mental Status Examination (MSE):

  • Appearance: [Details]

  • Behavior: [Details]

  • Speech: [Details]

  • Mood: [Details]

  • Affect: [Details]

  • Thought Process: [Details]

  • Thought Content: [Details]

  • Perception: [Details]

  • Insight: [Details]

  • Judgment: [Details]

  • Cognition: [Details]

Assessment: [Summary of findings and key differentials if relevant]
Diagnosis: [DSM-5 diagnoses and codes if applicable]

Plan:

  • Medications: [Start/continue/change; counseling provided]

  • Therapy: [Recommended approach and frequency]

  • Referrals/Labs: [If needed]

  • Follow-Up: [Timeframe]

  • Safety Plan: [If needed]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Psychiatric Evaluation

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Medication Follow-up]

Current Medications:

  • Medication Name: [Name]

  • Dosage/Frequency: [Dose, route, timing]

  • Indication: [Target symptom/diagnosis]

  • Adherence: [Missed doses, consistency, barriers]

Patient Report:

  • Symptom Response: [What improved, what persists, timeframe]

  • Side Effects: [Type, severity, onset, impact on functioning]

  • Concerns/Preferences: [Fears, goals, medication preferences]

Clinical Assessment:

  • Effectiveness: [Clinical impression of benefit]

  • Tolerability: [Risk/benefit, side effect management]

  • Safety Review: [Interactions, contraindications, monitoring needs]

Plan:

  • Medication Changes: [Continue/adjust/add/discontinue]

  • Education Provided: [Risks, benefits, expectations, adherence guidance]

  • Monitoring: [Vitals, labs, symptom tracking if needed]

  • Follow-Up: [Timeframe]

  • Crisis Guidance: [When to seek urgent care]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Medication Management

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Medication Follow-up]

Current Medications:

  • Medication Name: [Name]

  • Dosage/Frequency: [Dose, route, timing]

  • Indication: [Target symptom/diagnosis]

  • Adherence: [Missed doses, consistency, barriers]

Patient Report:

  • Symptom Response: [What improved, what persists, timeframe]

  • Side Effects: [Type, severity, onset, impact on functioning]

  • Concerns/Preferences: [Fears, goals, medication preferences]

Clinical Assessment:

  • Effectiveness: [Clinical impression of benefit]

  • Tolerability: [Risk/benefit, side effect management]

  • Safety Review: [Interactions, contraindications, monitoring needs]

Plan:

  • Medication Changes: [Continue/adjust/add/discontinue]

  • Education Provided: [Risks, benefits, expectations, adherence guidance]

  • Monitoring: [Vitals, labs, symptom tracking if needed]

  • Follow-Up: [Timeframe]

  • Crisis Guidance: [When to seek urgent care]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Medication Management

Template Sample

Patient Information
Name: [Patient Name]
Date of Birth: [MM/DD/YYYY]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Medication Follow-up]

Current Medications:

  • Medication Name: [Name]

  • Dosage/Frequency: [Dose, route, timing]

  • Indication: [Target symptom/diagnosis]

  • Adherence: [Missed doses, consistency, barriers]

Patient Report:

  • Symptom Response: [What improved, what persists, timeframe]

  • Side Effects: [Type, severity, onset, impact on functioning]

  • Concerns/Preferences: [Fears, goals, medication preferences]

Clinical Assessment:

  • Effectiveness: [Clinical impression of benefit]

  • Tolerability: [Risk/benefit, side effect management]

  • Safety Review: [Interactions, contraindications, monitoring needs]

Plan:

  • Medication Changes: [Continue/adjust/add/discontinue]

  • Education Provided: [Risks, benefits, expectations, adherence guidance]

  • Monitoring: [Vitals, labs, symptom tracking if needed]

  • Follow-Up: [Timeframe]

  • Crisis Guidance: [When to seek urgent care]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Medication Management

Template Sample

Patient Information
Name: [Patient Name]
Date of Session: [MM/DD/YYYY]
Session Type: [Individual / Family / Group]
Visit Type: [Ongoing / Follow-up]

Session Focus: [Primary theme(s) and goals for today]
Key Content: [Notable events, stressors, patterns discussed]

Client Presentation:

  • Mood: [Patient-reported]

  • Affect: [Clinician-observed]

  • Engagement: [Participation and openness]

Interventions Used:

  • Modality: [CBT/DBT/ACT/supportive/trauma-informed/etc.]

  • Techniques: [Specific exercises, reframes, exposures, skills]

  • Psychoeducation: [Topics and patient understanding]

Client Response:

  • Insight: [Learning or new perspective]

  • Skills Use: [Use of coping strategies, barriers]

  • Progress: [Movement toward goals with examples]

Plan:

  • Next Session Focus: [Planned goals/themes]

  • Homework: [Practice tasks and frequency]

  • Follow-Up: [Next appointment timeframe]

  • Safety Check: [If applicable]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Therapy Session

Template Sample

Patient Information
Name: [Patient Name]
Date of Session: [MM/DD/YYYY]
Session Type: [Individual / Family / Group]
Visit Type: [Ongoing / Follow-up]

Session Focus: [Primary theme(s) and goals for today]
Key Content: [Notable events, stressors, patterns discussed]

Client Presentation:

  • Mood: [Patient-reported]

  • Affect: [Clinician-observed]

  • Engagement: [Participation and openness]

Interventions Used:

  • Modality: [CBT/DBT/ACT/supportive/trauma-informed/etc.]

  • Techniques: [Specific exercises, reframes, exposures, skills]

  • Psychoeducation: [Topics and patient understanding]

Client Response:

  • Insight: [Learning or new perspective]

  • Skills Use: [Use of coping strategies, barriers]

  • Progress: [Movement toward goals with examples]

Plan:

  • Next Session Focus: [Planned goals/themes]

  • Homework: [Practice tasks and frequency]

  • Follow-Up: [Next appointment timeframe]

  • Safety Check: [If applicable]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Therapy Session

Template Sample

Patient Information
Name: [Patient Name]
Date of Session: [MM/DD/YYYY]
Session Type: [Individual / Family / Group]
Visit Type: [Ongoing / Follow-up]

Session Focus: [Primary theme(s) and goals for today]
Key Content: [Notable events, stressors, patterns discussed]

Client Presentation:

  • Mood: [Patient-reported]

  • Affect: [Clinician-observed]

  • Engagement: [Participation and openness]

Interventions Used:

  • Modality: [CBT/DBT/ACT/supportive/trauma-informed/etc.]

  • Techniques: [Specific exercises, reframes, exposures, skills]

  • Psychoeducation: [Topics and patient understanding]

Client Response:

  • Insight: [Learning or new perspective]

  • Skills Use: [Use of coping strategies, barriers]

  • Progress: [Movement toward goals with examples]

Plan:

  • Next Session Focus: [Planned goals/themes]

  • Homework: [Practice tasks and frequency]

  • Follow-Up: [Next appointment timeframe]

  • Safety Check: [If applicable]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Therapy Session

Template Sample

Patient Information
Name: [Patient Name]
Discharge Date: [MM/DD/YYYY]
Discharge Type: [Completed Treatment / Transfer of Care / Other]

Reason for Discharge: [Clinical completion, patient choice, referral, non-attendance, etc.]

Course of Treatment:

  • Start Date: [MM/DD/YYYY]

  • End Date: [MM/DD/YYYY]

  • Frequency: [Weekly/biweekly/etc.]

  • Interventions Provided: [Therapy modalities, medication management, education]

Progress Achieved:

  • Goals Addressed: [Goals worked on during care]

  • Outcomes: [Improvements, remaining symptoms, functional changes]

  • Current Status: [Symptoms and functioning at discharge]

Discharge Diagnosis: [Final diagnoses; DSM-5 codes if applicable]

Aftercare Plan:

  • Medications: [Current regimen and instructions, if applicable]

  • Referrals: [New providers, community resources]

  • Follow-Up Instructions: [Appointments, recommended timeframe]

  • Crisis Resources: [Emergency steps if symptoms worsen]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Discharge Summary

Template Sample

Patient Information
Name: [Patient Name]
Discharge Date: [MM/DD/YYYY]
Discharge Type: [Completed Treatment / Transfer of Care / Other]

Reason for Discharge: [Clinical completion, patient choice, referral, non-attendance, etc.]

Course of Treatment:

  • Start Date: [MM/DD/YYYY]

  • End Date: [MM/DD/YYYY]

  • Frequency: [Weekly/biweekly/etc.]

  • Interventions Provided: [Therapy modalities, medication management, education]

Progress Achieved:

  • Goals Addressed: [Goals worked on during care]

  • Outcomes: [Improvements, remaining symptoms, functional changes]

  • Current Status: [Symptoms and functioning at discharge]

Discharge Diagnosis: [Final diagnoses; DSM-5 codes if applicable]

Aftercare Plan:

  • Medications: [Current regimen and instructions, if applicable]

  • Referrals: [New providers, community resources]

  • Follow-Up Instructions: [Appointments, recommended timeframe]

  • Crisis Resources: [Emergency steps if symptoms worsen]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Discharge Summary

Template Sample

Patient Information
Name: [Patient Name]
Discharge Date: [MM/DD/YYYY]
Discharge Type: [Completed Treatment / Transfer of Care / Other]

Reason for Discharge: [Clinical completion, patient choice, referral, non-attendance, etc.]

Course of Treatment:

  • Start Date: [MM/DD/YYYY]

  • End Date: [MM/DD/YYYY]

  • Frequency: [Weekly/biweekly/etc.]

  • Interventions Provided: [Therapy modalities, medication management, education]

Progress Achieved:

  • Goals Addressed: [Goals worked on during care]

  • Outcomes: [Improvements, remaining symptoms, functional changes]

  • Current Status: [Symptoms and functioning at discharge]

Discharge Diagnosis: [Final diagnoses; DSM-5 codes if applicable]

Aftercare Plan:

  • Medications: [Current regimen and instructions, if applicable]

  • Referrals: [New providers, community resources]

  • Follow-Up Instructions: [Appointments, recommended timeframe]

  • Crisis Resources: [Emergency steps if symptoms worsen]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Discharge Summary

Template Sample

Patient Information
Name: [Patient Name]
Date of Encounter: [MM/DD/YYYY]
Encounter Type: [Phone / In-person / Telehealth / Walk-in]

Presenting Crisis: [What happened and why the patient is in crisis now]
Immediate Concerns: [Safety, acute symptoms, triggers, access to means]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan/intent/means/timeframe]

  • Homicidal Ideation: [Yes/No; plan/intent/means/timeframe]

  • Self-Harm Behavior: [Recent behavior or urges]

  • Protective Factors: [Supports, coping, reasons for living]

  • Risk Level: [Low / Moderate / High; rationale]

Interventions Provided:

  • De-escalation: [Grounding, breathing, validation, stabilization steps]

  • Safety Planning: [Means restriction, support contact, coping steps]

  • Coordination: [Contacted family/support, crisis team, EMS if needed]

  • Resources: [988, local crisis line, ER guidance]

Patient Response: [Engagement, emotional shift, acceptance of plan]

Plan:

  • Crisis Plan: [Step-by-step plan and contacts]

  • Follow-Up: [Immediate and near-term plan]

  • Documentation of Disposition: [Stayed home with plan, referred to ER, etc.]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Crisis Intervention

Template Sample

Patient Information
Name: [Patient Name]
Date of Encounter: [MM/DD/YYYY]
Encounter Type: [Phone / In-person / Telehealth / Walk-in]

Presenting Crisis: [What happened and why the patient is in crisis now]
Immediate Concerns: [Safety, acute symptoms, triggers, access to means]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan/intent/means/timeframe]

  • Homicidal Ideation: [Yes/No; plan/intent/means/timeframe]

  • Self-Harm Behavior: [Recent behavior or urges]

  • Protective Factors: [Supports, coping, reasons for living]

  • Risk Level: [Low / Moderate / High; rationale]

Interventions Provided:

  • De-escalation: [Grounding, breathing, validation, stabilization steps]

  • Safety Planning: [Means restriction, support contact, coping steps]

  • Coordination: [Contacted family/support, crisis team, EMS if needed]

  • Resources: [988, local crisis line, ER guidance]

Patient Response: [Engagement, emotional shift, acceptance of plan]

Plan:

  • Crisis Plan: [Step-by-step plan and contacts]

  • Follow-Up: [Immediate and near-term plan]

  • Documentation of Disposition: [Stayed home with plan, referred to ER, etc.]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Crisis Intervention

Template Sample

Patient Information
Name: [Patient Name]
Date of Encounter: [MM/DD/YYYY]
Encounter Type: [Phone / In-person / Telehealth / Walk-in]

Presenting Crisis: [What happened and why the patient is in crisis now]
Immediate Concerns: [Safety, acute symptoms, triggers, access to means]

Risk Assessment:

  • Suicidal Ideation: [Yes/No; plan/intent/means/timeframe]

  • Homicidal Ideation: [Yes/No; plan/intent/means/timeframe]

  • Self-Harm Behavior: [Recent behavior or urges]

  • Protective Factors: [Supports, coping, reasons for living]

  • Risk Level: [Low / Moderate / High; rationale]

Interventions Provided:

  • De-escalation: [Grounding, breathing, validation, stabilization steps]

  • Safety Planning: [Means restriction, support contact, coping steps]

  • Coordination: [Contacted family/support, crisis team, EMS if needed]

  • Resources: [988, local crisis line, ER guidance]

Patient Response: [Engagement, emotional shift, acceptance of plan]

Plan:

  • Crisis Plan: [Step-by-step plan and contacts]

  • Follow-Up: [Immediate and near-term plan]

  • Documentation of Disposition: [Stayed home with plan, referred to ER, etc.]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Crisis Intervention

Template Sample

Patient Information
Name: [Patient Name]
Plan Start Date: [MM/DD/YYYY]
Plan Type: [Initial / Updated]

Diagnosis: [Primary and secondary diagnoses; DSM-5 codes if applicable]

Problem List:

  • Problem 1: [Brief clinical problem statement]

  • Problem 2: [Additional problem statement]

Goals:

  • Goal 1: [Specific, measurable goal tied to problem]

  • Goal 2: [Specific, measurable goal tied to problem]

Objectives:

  • Objective 1: [Concrete steps patient will work on]

  • Objective 2: [Concrete steps patient will work on]

Interventions:

  • Intervention 1: [Therapy approach, frequency, focus]

  • Intervention 2: [Skills training, psychoeducation, referrals]

Expected Outcomes: [How progress will be measured, symptom scales, functioning markers]
Barriers: [Factors limiting progress, adherence, environment]
Strengths: [Protective factors, motivation, supports]

Review Date: [MM/DD/YYYY]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Treatment Plan

Template Sample

Patient Information
Name: [Patient Name]
Plan Start Date: [MM/DD/YYYY]
Plan Type: [Initial / Updated]

Diagnosis: [Primary and secondary diagnoses; DSM-5 codes if applicable]

Problem List:

  • Problem 1: [Brief clinical problem statement]

  • Problem 2: [Additional problem statement]

Goals:

  • Goal 1: [Specific, measurable goal tied to problem]

  • Goal 2: [Specific, measurable goal tied to problem]

Objectives:

  • Objective 1: [Concrete steps patient will work on]

  • Objective 2: [Concrete steps patient will work on]

Interventions:

  • Intervention 1: [Therapy approach, frequency, focus]

  • Intervention 2: [Skills training, psychoeducation, referrals]

Expected Outcomes: [How progress will be measured, symptom scales, functioning markers]
Barriers: [Factors limiting progress, adherence, environment]
Strengths: [Protective factors, motivation, supports]

Review Date: [MM/DD/YYYY]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Treatment Plan

Template Sample

Patient Information
Name: [Patient Name]
Plan Start Date: [MM/DD/YYYY]
Plan Type: [Initial / Updated]

Diagnosis: [Primary and secondary diagnoses; DSM-5 codes if applicable]

Problem List:

  • Problem 1: [Brief clinical problem statement]

  • Problem 2: [Additional problem statement]

Goals:

  • Goal 1: [Specific, measurable goal tied to problem]

  • Goal 2: [Specific, measurable goal tied to problem]

Objectives:

  • Objective 1: [Concrete steps patient will work on]

  • Objective 2: [Concrete steps patient will work on]

Interventions:

  • Intervention 1: [Therapy approach, frequency, focus]

  • Intervention 2: [Skills training, psychoeducation, referrals]

Expected Outcomes: [How progress will be measured, symptom scales, functioning markers]
Barriers: [Factors limiting progress, adherence, environment]
Strengths: [Protective factors, motivation, supports]

Review Date: [MM/DD/YYYY]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Treatment Plan

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Follow-up / Check-in]

Reason for Follow-Up: [Medication check, symptom follow-up, therapy follow-up, results review]
Interval Update: [Key events since last visit, stressors, changes]

Symptoms:

  • Mood/Anxiety: [Change and severity]

  • Sleep/Appetite/Energy: [Updates]

  • Functioning: [Work/school/home impact]

Assessment:

  • Clinical Impression: [Interpretation of current status]

  • Risk Review: [SI/HI denied or present; risk level]

  • Response to Treatment: [What is working and what is not]

Plan:

  • Adjustments: [Therapy plan, meds, goals, education]

  • Referrals: [If applicable]

  • Follow-Up: [Next visit timeframe]

  • Safety Plan: [If needed]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Follow-up Visit

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Follow-up / Check-in]

Reason for Follow-Up: [Medication check, symptom follow-up, therapy follow-up, results review]
Interval Update: [Key events since last visit, stressors, changes]

Symptoms:

  • Mood/Anxiety: [Change and severity]

  • Sleep/Appetite/Energy: [Updates]

  • Functioning: [Work/school/home impact]

Assessment:

  • Clinical Impression: [Interpretation of current status]

  • Risk Review: [SI/HI denied or present; risk level]

  • Response to Treatment: [What is working and what is not]

Plan:

  • Adjustments: [Therapy plan, meds, goals, education]

  • Referrals: [If applicable]

  • Follow-Up: [Next visit timeframe]

  • Safety Plan: [If needed]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Follow-up Visit

Template Sample

Patient Information
Name: [Patient Name]
Date of Visit: [MM/DD/YYYY]
Visit Type: [Follow-up / Check-in]

Reason for Follow-Up: [Medication check, symptom follow-up, therapy follow-up, results review]
Interval Update: [Key events since last visit, stressors, changes]

Symptoms:

  • Mood/Anxiety: [Change and severity]

  • Sleep/Appetite/Energy: [Updates]

  • Functioning: [Work/school/home impact]

Assessment:

  • Clinical Impression: [Interpretation of current status]

  • Risk Review: [SI/HI denied or present; risk level]

  • Response to Treatment: [What is working and what is not]

Plan:

  • Adjustments: [Therapy plan, meds, goals, education]

  • Referrals: [If applicable]

  • Follow-Up: [Next visit timeframe]

  • Safety Plan: [If needed]

Signature
Clinician Name: [Your Full Name]
Title: [Your Title]
Date: [MM/DD/YYYY]

Follow-up Visit

Template Sample

Security

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Security

Our technology is HIPAA-compliant, uses industry best practices, and doesn't store patient recordings.

Our Story

Blog

Templates

Terms of Service

Privacy Policy

© 2026 QlipHealth. All Rights Reserved.

Security

Our technology is HIPAA-compliant, uses industry best practices, and doesn't store patient recordings.

Our Story

Blog

Templates

Terms of Service

Privacy Policy

© 2026 QlipHealth. All Rights Reserved.

Security

Our technology is HIPAA-compliant, uses industry best practices, and doesn't store patient recordings.

Our Story

Blog

Templates

Terms of Service

Privacy Policy

© 2026 QlipHealth. All Rights Reserved.

Security

Our technology is HIPAA-compliant, uses industry best practices, and doesn't store patient recordings.

Our Story

Blog

Templates

Terms of Service

Privacy Policy

© 2026 QlipHealth. All Rights Reserved.