Generic Note Writing Template

Your Name:

Name of therapist/PP:

Date of Session:

Client Name:

Type of Session/Contact: (if family therapy or skills, indicate whether or not the consumer was present)

Time of Session:

*Be mindful to never use the word therapy/counseling/session in a skills contact, IE: Family Skills, Collateral Contact, Individual Skills.

BEHAVIOR: 4 sentences at least no matter the type of session; preferably 6. The following template covers everything for every agency. Feel free to copy/paste and use this each time to save your time and to make sure that everything is covered.

Example: The ___ met with ___ at ___ for a _____.  The purpose of the session/contact was _____. ____ appeared to be ____ aeb ____. When the ___ arrived, _____ was doing ______. _____ was appropriately dressed in a pair of jeans and a t-shirt. _____. ___ appeared to be oriented on all spheres. There were no signs of SI/HI. ___ Exhibited appropriate eye contact throughout the session/contact. ____ appeared to be in a ___ mood.

Intervention 6 sentences for an hour for Precious/Gloria. An additional sentence for each 15 minutes. DG always gets at least 12 sentences. Ebone is 600-800 words. If this is therapy, make sure to talk about a modality, usually CBT. If it is skill building, no modality, just teaching.

Response6 sentences for an hour for Precious/Gloria. An additional sentence for each 15 minutes. DG always gets at least 12 sentences. Ebone is 600-800 words. At least one quote, pref more from person at session.

Plan:

The ___ will meet with ___ within a week to _____. ____ is not yet ready yet to discharge due to ______.

Progress:

(Some/little/no/moderate) progress was indicated this session/contact, evidenced by ______.