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Lorraine Quintana
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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.
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.
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:
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:
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 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 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."
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:
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.
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:
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.
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:
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.
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.
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.
While a general template can be adapted, it’s best to use tailored templates for specific therapies such as ABA, RBT, or counseling. Since each template will have a different focus, this ensures you capture only the most relevant details, as well as meet industry-specific requirements.
