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