Session Notes Template
This psychology session notes template helps you accurately and efficiently document follow-up therapy sessions. In Australia, psychology session notes typically support care delivered under Medicare's Better Access initiative and need to meet the record-keeping standards set out in the Psychology Board of Australia's Code of Conduct. Heidi structures your notes to reflect both the clinical content of the session and the documentation standard your registration requires.
- Review out-of-session tasks and client-reported progress to assess therapeutic engagement and impact.
- Log current client presentation, session content, and applied interventions to support evidence-based treatment.
- Document risk factors, mental status findings, and planned next steps to ensure continuity of care and clinical compliance.
What is a Session Notes Template?
A session notes template is a standardised document used by therapists, counsellors, Applied Behavior Analysis (ABA) therapists, and Registered Behavior Technicians (RBTs) to record key details from therapy sessions. These templates typically dedicate sections to documenting the session’s date, type, presenting issues, interventions used, and patient responses.
In this article, we’ll discuss the importance of session note templates and the different types of templates used in clinical practise, provide a step-by-step guide on how you can use them effectively, and share customisable, ready-to-use session note templates for your daily practise.
Why Session Note Templates Matter for Australian Clinicians
Session notes are critical for tracking client progress, supporting continuity of care, and meeting legal and ethical standards in healthcare. A well-designed session notes template not only streamlines documentation; it also reduces the risk of errors, saves valuable time, and ensures that essential details are consistently captured in a clear and organised format.
To ensure your template aligns with the Australian Privacy Principles and the relevant professional Code of Conduct, such as the Psychology Board of Australia's, clinicians should:
- Avoid including excessive personal details or non-clinical commentary.
- Use secure, encrypted platforms to store and manage records.
- Follow industry-specific guidelines (such as ABA or counselling standards).
- Regularly review and update templates to align with the latest regulations.
Types of Session Notes Templates
Session notes templates must be tailored to the needs of specific healthcare professionals to ensure effectiveness and compliance with regulatory standards. While the general structure across templates may be similar, the content and focus of each note vary based on the type of service being provided by the clinician.
Let’s talk about the most common session notes templates being used in healthcare today:
ABA Session Notes Template
Applied Behavior Analysis (ABA) session notes are used to track behavior interventions and client progress over several ABA therapy sessions.
ABA-based interventions focus on behaviours considered relevant to an individual’s wellbeing and independence, which may include social skills, communication, and daily living skills.
Behaviour support in Australia is delivered under the National Disability Insurance Scheme (NDIS) and operates within the Positive Behaviour Support framework set by the NDIS Quality and Safeguards Commission.
This type of template typically dedicates sections to key data such as target behaviors, therapist observations, and reinforcement strategies, focusing on the collection of objective, measurable data to support behavior plans and treatment adjustments.
RBT Session Notes Template
RBT sessions are delivered by Registered Behaviour Technicians to help individuals with Autism Spectrum Disorder (ASD) and other developmental disabilities.
RBT templates often include key elements such as the session’s date and time, specific skills worked on, behavior incidents, prompts used, and any deviations from the therapy plan. RBTs typically avoid interpretation or diagnosis and focus on documenting observable and reportable facts.
RBT Session Notes Template
RBT sessions are delivered by Registered Behaviour Technicians to help individuals with Autism Spectrum Disorder (ASD) and other developmental disabilities.
RBT templates often include key elements such as the session’s date and time, specific skills worked on, behavior incidents, prompts used, and any deviations from the therapy plan. RBTs typically avoid interpretation or diagnosis and focus on documenting observable and reportable facts.
Dr. Theresa Colina runs Tuggerah Family Doctors in NSW, Australia, where back-to-back 15-to 20-minute visits left little room for the part of the job she trained for.
Since adopting Heidi, Theresa gets at least an hour back each day, with notes finished before the patient leaves the room and letters generated in minutes.
"I feel like my patients got me back," she says. "They appreciate the fact that I'm actually looking at them and talking to them."
How to Use a Session Notes Template: Step-by-Step Guide
Heidi is designed to streamline the clinical documentation process by eliminating the need for manual note-taking.
Below is a step-by-step guide to completing your session notes with Heidi:
Download a Session Notes Template
While you can easily create your own AI-enabled templates in Heidi, the fastest way to get started is by downloading one from our template community. Here, you can search for and download your preferred session notes templates for free.
Customise for Your Practise (As Needed)
The templates from our collection are designed for immediate use, but you also have the option to customise them to ensure they suit your needs and preferences. To do this, you just need to:
- Log in to Heidi, then go to your template library by clicking the templates option on the left-hand side of the menu.
- Find the template you want to edit by searching for it or browsing the template list.
- Click on the 3-dot menu on the right-hand side of the list.
- Click edit, make the desired changes, and then click save.
Ensure that the template aligns with both the ethical framework of the Psychotherapy and Counselling Federation of Australia (PACFA) and any relevant policies of your specific employing organisation.
Start a Session
With your client’s permission, simply hit Start on your computer or mobile device to start the audio recording, and let Heidi work in the background while you conduct your session as normal. For information that you don’t want to verbalise, you can type it under the context notes section to be considered later.Generate Your Completed Session Notes
After the session, simply select your preferred session notes template and watch as Heidi perfectly transcribes the details of your session and context notes in the appropriate fields and format! You can even ask Heidi to generate additional documentation such as progress notes, treatment plans, or referral letters, as needed.
Session Notes Template Example
Easily Complete AU-based Session Notes with Heidi
Manually writing session notes often presents a frustrating trade-off between having to focus on the session and the need to document it. Here’s how Heidi improves your documentation process:
- Save Valuable Time – Burnout via administrative tasks is a real issue in the healthcare industry. With Heidi, you no longer have to spend an extra 2-3 hours just to catch up on your notes.
- Improve Patient Care – Patients may feel frustrated if they perceive their therapists to be more engaged in writing notes instead of being completely present during sessions. Heidi allows clinicians to give their full attention to their clients without having to worry about forgotten information.
- Ensure Compliance – Heidi captures clinical details in real time, reducing the risk of incomplete documentation. Through structured templates and AI-generated notes tailored to your practise, you can maintain high standards of clinical accuracy while meeting the Australian Privacy Principles.
Heidi complies with jurisdiction-specific regulations, including the Australian Privacy Principles (APPs), with data localisation available for customers across the globe. Read more about our compliance here.
Free Session Notes Templates
CBT Session Notes Template
This CBT session note template helps psychiatrists, psychologists, and counsellors document cognitive-behavioral therapy sessions. It includes sections for session objectives, review of previous sessions, patient’s current issues, cognitive and behavioural interventions, homework assignments, and plans for future sessions.
Initial Session Note Template
This initial session note template is specifically designed for use by trauma therapists working with clients in an ACT-based framework. The structure follows the six key processes of the ACT Hexaflex, ensuring that all relevant aspects of the session are documented in a clear, structured manner.