Health Psychology Consultation Note

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™

Template

Health Psychologist Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
[Presenting psychological concern or reason for referral]
[Duration, onset, and course of symptoms]
[Associated stressors, triggers, or relevant life events]
[Impact on functioning, relationships, work, or school]
[Previous interventions or coping strategies attempted]

Past Psychiatric History:
(hyphenated list)
- [Previous psychiatric diagnoses]
- [Prior hospitalizations or treatments]
- [History of psychotherapy or counseling]
- [Suicidal ideation or self-harm history]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [Chronic illnesses]
- [Surgical history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Sertraline 50 mg oral daily)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family Psychiatric History:
(hyphenated list)
- [Relative: Psychiatric diagnosis or relevant history]
- (e.g., Father: Major depressive disorder)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Relationship status and supports]
- [Education level]

Mental Status Examination:
(hyphenated list)
- [Appearance: grooming, dress]
- [Behavior: eye contact, psychomotor activity]
- [Mood and affect: description]
- [Speech: rate, volume, coherence]
- [Thought process: organization, logic]
- [Thought content: delusions, obsessions, suicidal/homicidal ideation]
- [Cognition: orientation, attention, memory]
- [Insight and judgment]

Physical Examination (if performed):
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Relevant physical findings]

Investigations:
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary psychological concern]

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line if mentioned)
- [Psychological formulation and diagnosis]
- [Therapeutic recommendations (e.g., CBT, mindfulness, behavioral activation)]
- [Medication recommendations if applicable]
- [Counseling or psychoeducation provided]
- [Referrals to other providers or services]
- [Follow up plan]
- [Safety planning or crisis resources]
- [Return precautions]