All community templates
Template structure
This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.
Counselor Note Identifying Information: [Client name, age, gender, relevant background] Presenting Problem: [Brief statement of reason for visit or referral] [Duration and context of presenting issue] History: (hyphenated list) - [Relevant psychosocial history] - [Past psychiatric history] - [Medical history] - [Family history] - [Social history] - [Substance use history] Mental Status Examination: (hyphenated list) - [Appearance] - [Behavior] - [Mood] - [Affect] - [Speech] - [Thought process] - [Thought content] - [Perceptions] - [Cognition] - [Insight] - [Judgment] Interventions: (hyphenated list) - [Therapeutic techniques used] - [Client response to interventions] - [Skills or strategies discussed] - [Homework or assignments given] Assessment: (hyphenated list) - [Summary of client’s current status] - [Progress toward goals] - [Barriers or challenges identified] Plan: (hyphenated list) - [Goals for next session] - [Planned interventions] - [Referrals or resources provided] - [Follow up arrangements]
Shared by
SO
Sarah O’Connell
Mental Health Counselor, Ireland
How it works in Notat
Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.
Try Notat — it’s free