Marriage and family therapist Template

Rula Template

A professional Marriage and family therapist template for healthcare professionals.

About this template

Looking for a clear and concise way to document your sessions? This Rula template is designed for marriage and family therapists to streamline their note-taking process. It helps you capture essential details like current symptoms, the impact on the client's life, session focus, treatment approaches, and the plan moving forward. This template ensures you're documenting all the key elements of each session. With Heidi, the AI scribe, this template can be automatically populated from your session transcript, saving you valuable time and ensuring comprehensive documentation. Start using this template today to improve your clinical documentation.

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Current symptoms: Anxiety, panic attacks, and feelings of hopelessness. Client reports experiencing panic attacks several times a week, accompanied by shortness of breath, heart palpitations, and a sense of impending doom. They also report feeling hopeless about their future and struggling to find joy in activities they used to enjoy. Client's current clinical presentation includes a moderate level of anxiety, with frequent panic attacks and symptoms of depression. Symptoms have worsened over the past month, with an increase in the frequency and intensity of panic attacks and a deepening of feelings of hopelessness. How are symptoms specifically impacting client's functioning: The client's symptoms are significantly impairing their ability to function socially and at work. They have withdrawn from social activities due to fear of panic attacks and are finding it difficult to concentrate at work, leading to decreased productivity and increased stress. Focus of session/session summary: The session focused on exploring the client's current symptoms and triggers, as well as developing coping strategies for managing anxiety and panic attacks. We discussed the client's recent experiences and identified specific situations that trigger their panic attacks. We also explored the client's feelings of hopelessness and discussed potential sources of support and activities that might bring them joy. Treatment approaches used in this session: Cognitive Behavioral Therapy (CBT) and psychoeducation. Specific interventions: We used cognitive restructuring techniques to challenge negative thoughts and beliefs associated with panic attacks. We also practiced deep breathing exercises and progressive muscle relaxation to manage physical symptoms of anxiety. Psychoeducation was provided regarding the nature of anxiety and panic disorders. Client response to interventions: The client reported feeling slightly less anxious after practicing the deep breathing exercises. They expressed a willingness to try the cognitive restructuring techniques and felt hopeful about the possibility of managing their symptoms. Plan: The client will practice deep breathing exercises twice a day and will begin to identify and challenge negative thoughts using the cognitive restructuring techniques discussed in the session. They will also keep a journal to track their panic attacks and identify potential triggers. The client will also be encouraged to engage in activities that they used to enjoy to combat feelings of hopelessness. The client will also be encouraged to use their safety plan if needed.

Current symptoms: [Current symptoms from measures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Symptoms discussed and presented in session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Description of current clinical presentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [New/recent symptom progression or regression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) How are symptoms specifically impacting client's functioning: [Describe how client's symptoms are impairing their ability to function socially/relationally, at work/school, activities of daily living or any other area] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Focus of session/session summary: [Describe specifically what happened in the session with the client] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Treatment approaches used in this session: [List treatment approaches used in this session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Specific interventions: [List specific interventions used in this session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Client response to interventions: [Describe the client's response to the interventions provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: [Describe what the client will do in between sessions to make progress towards treatment goal(s)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Include details about homework, skills practice, and/or use of safety plan, if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)

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