List of Available Note Templates

List of Available Note Templates

The following is a list of all note templates currently available for use. 

Session Note Templates

·      CBT Note fields

o   Today’s Agenda

o   Homework Compliance

o   Notes

o   Symptoms

o   Interventions

o   New Homework

o   Next Session’s Agenda

o   Psychotherapy Note

·      SOAP Note fields

o   Chief Complaint

o   Subjective/HPI

o   Objective

o   Assessment/Diagnosis

o   Plan/Recommendation

o   Psychotherapy Note

·      Acupuncture Note fields

o   SAME AS SOAP

o   Additional Diagram field

·      General Note fields

o   Note

o   Psychotherapy Note

·      CBT Note (Auto-Text) fields

o   Today’s Agenda

o   Homework Compliance

o   Notes

-  Auto-Text Options:

·      ACT

·      Anger Management

·      Cognitive Therapy

·      DBT

·      Dialectic Strategies

·      EMDR

·      Exposure

·      MSE (Mental Status Exam)

·      Occupational Therapy

·      REBT

·      Risk Assessment

o   Symptoms

o   Interventions

o   New Homework

o   Next Session’s Agenda

o   Psychotherapy Note

·      Therapy Note fields

o   Primary Focus

o   Interventions

o   Plan for Next Appointment

o   Risk

o   Psychotherapy Note

·      Standard Therapy Note fields

o   Client Presentation and Risk Assessment

o   Therapeutic Intervention and Response

o   Progress Towards Goals

o   Other (Insurance authorizations, Homework, etc.)

o   Psychotherapy Note

Treatment Plan Templates

·      CBT Treatment Plan fields

o   Basic Information, Background, and Notes

o   Treatment Plan

·      General Treatment Plan fields

o   Treatment Plan

Case Conceptualization Templates

·      ACT Case Conceptualization fields

o   Goals

o   Avoided Emotions

o   Avoided Thoughts

o   Avoided Sensations

o   Avoidant/Escape Motor Behaviors

o   Avoidant/Escape Covert Behaviors

o   Values to Prioritize

o   Unclarified Values

o   Committed Actions

o   Barriers to Growth

·      Psychotherapy Case Conceptualization & General Case Conceptualization fields

o   Case Conceptualization

·      REBT Case Conceptualization fields

o   Activating Events

o   Beliefs

o   Consequences

o   Disputations

o   Effective New Beliefs

o   Feelings and Behaviors

·      5 P’s Case Conceptualization fields

o   Activating Events

o   Beliefs

o   Consequences

o   Disputations

o   Effective New Beliefs

Intake Interview Templates

·      Psychotherapy Intake Interview fields

o   Chief Complaint

o   History of Present Illness

o   Past Psychiatric History

o   Medical History / Screen

o   Substance Abuse History

o   Social History

o   Family History

o   Assessment

o   Diagnosis

o   Recommendation / Plan

o   MMSE

·      CBT Intake Interview & General Intake Interview fields

o   Interview

 


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