574 uses
Cognitive Behavioral Therapy Note
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Finished note
Example — generated by Notat from a sample visit
Presenting concern: Reports increased anxiety and disrupted sleep during a period of work-related stress. Denies thoughts of self-harm. Assessment: Anxiety symptoms affecting sleep and daily functioning; no immediate safety concern disclosed. Plan: Discussed coping strategies, sleep routine, and follow-up. Patient knows how to seek urgent support if safety concerns arise. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Anxiety: Increased anxiety during work-related stress
Sleep: Disrupted sleep
denials of symptoms
Denies: Risk: Denies thoughts of self-harm
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
plan
Support: Coping strategies, sleep routine, and follow-up discussed
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
Cognitive Behavioural Therapist Consult Note Patient Identification: [Patient name, age, gender, relevant background, presenting concern] History of Present Illness: [Description of presenting symptoms, onset, duration, frequency, severity, and impact on functioning] [Relevant stressors, triggers, or precipitating events] [Previous coping strategies and their effectiveness] [Motivation and goals for therapy] Past Psychiatric History: (hyphenated list) - [Previous psychiatric diagnoses] - [Prior hospitalizations or treatments] - [History of self-harm or suicidality] - [Previous therapy modalities and response] Past Medical History: (hyphenated list) - [Relevant medical conditions] - [Chronic illnesses] - [Surgical history] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - [Psychotropic and non-psychotropic medications] Allergies: (hyphenated list) - [Drug, food, or environmental allergies] - [No known drug allergies (NKDA) if applicable] Family Psychiatric History: (hyphenated list) - [Relative: Psychiatric diagnosis or relevant history] - [Suicide or self-harm in family] Social History: (hyphenated list) - [Living situation: who lives with patient, home environment] - [Relationship status and supports] - [Occupation, education, financial stressors] - [Substance use: type, amount, frequency] - [Legal issues or involvement] Mental Status Examination: (hyphenated list) - [Appearance and behaviour] - [Mood and affect] - [Speech and language] - [Thought process and content] - [Perceptions] - [Cognition: orientation, attention, memory] - [Insight and judgement] - [Risk assessment: suicidality, self-harm, harm to others] Assessment: (hyphenated list) - [Primary psychiatric diagnosis or presenting problem] - [Contributing factors and formulation] - [Differential diagnosis if relevant] Plan: (hyphenated list) - [CBT treatment goals] - [Interventions planned (e.g., cognitive restructuring, behavioural activation, exposure exercises)] - [Homework assignments] - [Psychoeducation provided] - [Safety planning if indicated] - [Referrals to other providers if needed] - [Frequency and duration of sessions] - [Follow up plan] - [Return precautions]
Shared by
SO
Sarah O’Connell
Mental Health Counselor, Ireland
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