[Client Name] Sarah Jones
[Session Date] 1 November 2024
[Who was present during the session] Sarah Jones and Psychologist
[Session type] Face-to-face
[Session setting] Clinic
Current Presentation:
Sarah presented with ongoing anxiety and difficulties managing social situations. She reported feeling overwhelmed in crowded environments and experiencing panic attacks.
[Impact of issues on functioning or wellbeing] These issues significantly impact her ability to attend school regularly and participate in social activities, leading to feelings of isolation and low self-esteem.
NDIS Goals Addressed:
[NDIS goals targeted in this session] Improve social participation and manage anxiety symptoms.
[Client’s engagement in activities aligned to goals] Sarah actively participated in role-playing social scenarios and practicing relaxation techniques.
[Functional capacity observed in this session] Sarah demonstrated improved ability to identify triggers and implement coping strategies during the session.
Progress Toward Goals:
[Summary of progress or barriers relating to NDIS goals] Sarah is making progress in identifying her anxiety triggers and using coping mechanisms. Barriers include ongoing stress related to school and social pressures.
NDIS Therapeutic Approach:
[Therapy modalities or frameworks used, e.g. CBT, DBT, ACT, Social Skills Training] Cognitive Behavioural Therapy (CBT) and Social Skills Training.
Interventions:
- [Therapeutic, cognitive, emotional or skill-building strategies used during session] Cognitive restructuring to challenge negative thoughts, relaxation techniques (deep breathing), and exposure exercises.
- [Structured methods applied to address goals or build functional skills] Role-playing social situations, practicing assertive communication, and developing a plan for managing anxiety in social settings.
Key Activities:
- [Insert description of activities conducted in the session] Discussed anxiety triggers, practiced deep breathing exercises, and role-played a social interaction.
- [Resources or tools used during session] Anxiety management worksheets and a relaxation audio guide.
- [Focus area for skills development] Improving social skills and managing anxiety symptoms.
Session Content:
- [Themes, ideas, or concerns explored] Anxiety triggers, negative thought patterns, and social avoidance.
- [Client insights or reflections] Sarah recognised the link between her thoughts and feelings, and expressed a desire to challenge her negative thought patterns.
- [Discussion of family, school or community context] Discussed the impact of school and social pressures on her anxiety levels.
Progress and Barriers:
- [Signs of progress toward therapy or NDIS goals] Sarah demonstrated improved ability to identify her anxiety triggers and use coping mechanisms.
- [Barriers, setbacks, or environmental factors influencing progress] Ongoing stress related to school and social pressures.
Client Response:
[Level and nature of client engagement (e.g. calm, dysregulated, avoidant)] Engaged and cooperative.
[Emotional or behavioural responses during session] Calm and reflective.
[Non-verbal indicators of engagement or distress] Maintained eye contact and actively participated in exercises.
Caregiver Involvement:
[Was caregiver involved in session?] No
[Summary of caregiver input, concerns, or observations] N/A
Risk Assessment and Management:
- Suicidal ideation: [Description of suicidal thoughts, plans or history] None reported.
- Homicidal ideation: [Description of any harm-to-others ideation] None reported.
- Self-harm: [Past or present self-harming behaviours] None reported.
- Violence or aggression: [History or signs of aggressive behaviour] None reported.
- Addictive behaviours: [Illicit substance use, gambling, or dependency] None reported.
- Risk-taking/impulsivity: [Behavioural impulsivity or risky actions] None reported.
- Management plan: [Documented strategy for managing risks above] N/A
Risks or Alerts:
[Description of identified risk] None identified.
[Actions taken in response to risk] N/A
Session Outcomes:
[Summary of outcomes including client progress, insight, or difficulties] Sarah demonstrated improved understanding of her anxiety triggers and practiced coping mechanisms. She identified the link between her thoughts and feelings and expressed a desire to challenge her negative thought patterns.
Next Steps:
[Focus for next session] Continue working on cognitive restructuring and exposure exercises.
[Homework, skills practice, or tracking tasks assigned] Practice deep breathing exercises daily and complete a thought record.
[Recommendations for collaboration with school/family/community] Encourage Sarah to discuss her anxiety with her school counsellor.
Reporting Summary:
NDIS goals targeted: Improve social participation and manage anxiety symptoms.
Presenting issues: Anxiety and difficulties managing social situations.
Interventions: Cognitive restructuring, relaxation techniques, and exposure exercises.
Therapy models: CBT and Social Skills Training.
Therapeutic support provided: Cognitive restructuring, relaxation techniques, and exposure exercises.
How supports helped: These supports helped Sarah develop skills to manage her anxiety and improve her social participation.
Client engagement: Engaged and cooperative.
Barriers: Ongoing stress related to school and social pressures.
Functional capacity observed: Demonstrated improved ability to identify triggers and implement coping strategies.
Progress made: Improved understanding of anxiety triggers and the ability to use coping mechanisms.
[Client Name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Session Date] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Who was present during the session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Session type] (Select from: Face-to-face, Telehealth, Phone, Other) (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Session setting] (Select from: Clinic, Home, School, Community, Online, Other) (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Current Presentation:
[Presenting issue or concern discussed in session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
[Impact of issues on functioning or wellbeing] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
NDIS Goals Addressed:
[NDIS goals targeted in this session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
[Client’s engagement in activities aligned to goals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
[Functional capacity observed in this session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
Progress Toward Goals:
[Summary of progress or barriers relating to NDIS goals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points or paragraph format as appropriate.)
NDIS Therapeutic Approach:
[Therapy modalities or frameworks used, e.g. CBT, DBT, ACT, Social Skills Training] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
Interventions:
- [Therapeutic, cognitive, emotional or skill-building strategies used during session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
- [Structured methods applied to address goals or build functional skills] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Key Activities:
- [Insert description of activities conducted in the session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
- [Resources or tools used during session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
- [Focus area for skills development] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
Session Content:
- [Themes, ideas, or concerns explored] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use bullet points.)
- [Client insights or reflections] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
- [Discussion of family, school or community context] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
Progress and Barriers:
- [Signs of progress toward therapy or NDIS goals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph or bullet points.)
- [Barriers, setbacks, or environmental factors influencing progress] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph or bullet points.)
Client Response:
[Level and nature of client engagement (e.g. calm, dysregulated, avoidant)] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
[Emotional or behavioural responses during session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
[Non-verbal indicators of engagement or distress] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in sentence format.)
Caregiver Involvement:
[Was caregiver involved in session?] (Select: Yes, No) (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Summary of caregiver input, concerns, or observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
Risk Assessment and Management:
- Suicidal ideation: [Description of suicidal thoughts, plans or history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Homicidal ideation: [Description of any harm-to-others ideation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Self-harm: [Past or present self-harming behaviours] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Violence or aggression: [History or signs of aggressive behaviour] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Addictive behaviours: [Illicit substance use, gambling, or dependency] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Risk-taking/impulsivity: [Behavioural impulsivity or risky actions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
- Management plan: [Documented strategy for managing risks above] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Risks or Alerts:
[Description of identified risk] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Actions taken in response to risk] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Session Outcomes:
[Summary of outcomes including client progress, insight, or difficulties] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
Next Steps:
[Focus for next session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Homework, skills practice, or tracking tasks assigned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Recommendations for collaboration with school/family/community] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Reporting Summary:
NDIS goals targeted: [NDIS goals addressed in this session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Presenting issues: [Main presenting concerns or functional issues this session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Interventions: [Key therapeutic interventions used this session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Therapy models: [Models/frameworks used, e.g. CBT, ACT] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Therapeutic support provided: [Supports that improved functional capacity in areas such as communication, self-care, mobility, psychosocial or community functioning] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
How supports helped: [Describe how the support helped develop skills, confidence, and reduce dependence on support over time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph format.)
Client engagement: [Client’s engagement level and style] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Barriers: [Obstacles, stressors or environmental limitations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Functional capacity observed: [Skills demonstrated in the session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Progress made: [Key areas of growth or skill acquisition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(Never come up with your own client details, assessment, plan, interventions, evaluation, or support strategies – use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. Only include a placeholder if it has been explicitly mentioned in the transcript or context — otherwise omit the section completely. Always write numbers (e.g. session duration, percentage progress, NDIS goals) in digits not in words. Use bullet points, paragraphs or numbered lists depending on the format of the information provided.)
