"1. Date and Time of Contact": "1 November 2024, 10:30 AM",
"2. Mode of Communication": "Phone call",
"3. Initiator of Contact": "Client",
"4. Purpose of Contact": "Client called to report increased anxiety and difficulty sleeping.",
"5. Summary of Interaction": "Client reported feeling overwhelmed by recent work deadlines and social events. They described experiencing racing thoughts and a sense of impending doom. They also mentioned difficulty falling asleep and staying asleep for the past week. The client denied any suicidal ideation or plans.",
"6. Action Taken / Response": "Provided immediate support and active listening. Offered coping strategies for anxiety, including deep breathing exercises and mindfulness techniques. Encouraged the client to engage in relaxing activities before bed. Documented the call in the client's record. No follow-up needed at this time.",
"7. Plan or Next Steps": "Client to continue using coping strategies. Advised client to contact the crisis line if symptoms worsen. Scheduled a follow-up session for next week to assess progress.",
"8. Signature and Credentials": "Dr. Eleanor Vance, LPC, 1 November 2024"
1. Date and Time of Contact:
[Exact date and time the contact occurred or was received.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
2. Mode of Communication:
[Mode of communication such as phone call, voicemail, text message, email, in-person drop-in, client portal, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
3. Initiator of Contact:
[Who initiated the contact, such as client, counselor, parent, case worker.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
4. Purpose of Contact:
[Brief reason for the communication, such as scheduling, crisis, medication question, clarification of homework, progress update.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
5. Summary of Interaction:
[Brief, objective summary of what was discussed or conveyed. Do not include personal judgments or lengthy clinical analysis.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
6. Action Taken / Response:
[What the counselor did in response, such as returned call, clarified information, documented the message. Whether a follow-up is needed.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
7. Plan or Next Steps:
[Any decisions or actions to take moving forward, such as adjust treatment plan, notify supervisor, schedule session.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
8. Signature and Credentials:
[Counselor's name, date, and title.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)