Cognitive Behavioral Therapy Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

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]