Clinical Physiologist Template

Psychological therapy note

A professional Clinical Physiologist template for healthcare professionals.

About this template

Need a clear and concise way to document your therapy sessions? Our 'Psychological Therapy Note' template is designed for clinical psychologists and other mental health professionals. This template helps you capture key details from each session, including the client's presenting issues, agreed-upon agenda, therapeutic conversations, and any homework assigned. It also includes a section to assess and manage risk. With this template, you can create detailed and organised progress notes, ensuring accurate and efficient documentation. Easily create your notes with Heidi's AI scribe, saving you time and improving the quality of your clinical documentation. This template is perfect for creating detailed and compliant mental health documentation.

Preview template

Client Consultation Note: Summarise main topics client has brought to therapy, including reasons for visit, presenting issues, and any relevant background information: The client, a 35-year-old female, presented today with symptoms of anxiety and panic attacks, which she reports have been increasing in frequency and intensity over the past month. She reports difficulty sleeping, racing thoughts, and physical symptoms such as heart palpitations and shortness of breath. She also reports a recent stressful event at work, which she believes has triggered the exacerbation of her symptoms. She has a history of anxiety, but has not sought therapy in the past. Summarise any agenda agreed upon for the session, including specific goals or topics to be addressed: The agenda for today's session included exploring the client's current symptoms, identifying potential triggers, and discussing initial coping strategies. The client and therapist agreed to focus on relaxation techniques and cognitive restructuring. Summarise the main therapeutic conversation, including key points discussed, insights gained, and any therapeutic techniques or interventions used: The therapist and client discussed the client's recent stressful event at work, exploring the impact it has had on her mental state. The therapist used cognitive restructuring techniques to challenge negative thought patterns and help the client reframe her situation. The client was encouraged to identify and challenge her anxious thoughts. The therapist also introduced the concept of diaphragmatic breathing as a relaxation technique, and the client practiced this during the session. The client reported feeling slightly calmer after practicing the technique. Summarise any homework or agreements for topics to explore in future sessions, including specific tasks or areas of focus: The client agreed to practice diaphragmatic breathing twice a day and to keep a journal of her anxious thoughts and the situations that trigger them. The next session will focus on identifying and challenging negative thought patterns. Risk: Summarise any updates or changes in the client's risk status, including any new concerns or improvements: The client denied any current suicidal ideation or plans for self-harm. She reported feeling overwhelmed but not hopeless. Her risk status is currently considered low. Summarise any plans for managing risk agreed with the client, including specific strategies or interventions: The client was provided with a list of crisis resources and encouraged to contact the therapist or a crisis hotline if her symptoms worsen. The therapist will monitor her progress and assess her risk status in future sessions.

Client Consultation Note: [Summarise main topics client has brought to therapy, including reasons for visit, presenting issues, and any relevant background information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Summarise any agenda agreed upon for the session, including specific goals or topics to be addressed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Summarise the main therapeutic conversation, including key points discussed, insights gained, and any therapeutic techniques or interventions used] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Summarise any homework or agreements for topics to explore in future sessions, including specific tasks or areas of focus] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Risk: [Summarise any updates or changes in the client's risk status, including any new concerns or improvements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) [Summarise any plans for managing risk agreed with the client, including specific strategies or interventions] (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.)

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