Therapy Session 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

Therapist Note

Identifying Information:
[Patient name], [age], [gender], [date of session], [type of session: individual, group, family]

Presenting Problem:
[Brief description of reason for therapy or current concerns]

History:
[Relevant background information, including psychiatric history, medical history, family history, social history]

Mental Status Examination:
(hyphenated list)
- Appearance: [description]
- Behavior: [description]
- Mood: [description]
- Affect: [description]
- Thought process: [description]
- Thought content: [description]
- Perceptions: [description]
- Cognition: [description]
- Insight: [description]
- Judgment: [description]

Interventions:
(hyphenated list)
- [Therapeutic techniques used during session]
- [Skills practiced or introduced]
- [Homework assigned if applicable]

Response to Intervention:
[Patient’s response to interventions, engagement level, progress toward goals]

Assessment:
[Clinical impressions, changes in symptoms, risk assessment if relevant]

Plan:
(hyphenated list)
- [Goals for next session]
- [Planned interventions]
- [Referrals or coordination with other providers]
- [Follow-up appointment date]
- [Safety plan or crisis plan if applicable]