Mental Health Counselor Template

Mental health note HEADSS Ax

A professional Mental Health Counselor template for healthcare professionals.

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Specialty

Mental Health Counselor

Used

85 times

Type

Note

Last edited

9/20/2024

Created by

Indira Gankanda

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About this template

This mental health note template is designed for mental health counselors conducting a HEADSS assessment. It covers key areas such as home environment, education, activities, substance use, sexuality, mental health, and safety. This comprehensive template helps clinicians gather essential information to understand the patient's psychosocial context. Ideal for mental health professionals, this template ensures a thorough evaluation of adolescent patients, facilitating effective treatment planning. When used with Heidi, the AI medical scribe, it streamlines documentation, allowing counselors to focus more on patient care.

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HEADSS assessment: Home Environment: - The patient lives with their parents and two younger siblings. Family dynamics are generally positive, with open communication and supportive relationships. Education and Employment: - The patient is a high school junior with average grades. Attendance is consistent, and they have a good rapport with teachers and peers. The patient works part-time at a local café and reports satisfaction with the job. Activities: - The patient enjoys playing basketball and is part of the school team. They have a close-knit group of friends and engage in regular social activities. Drugs: - The patient occasionally consumes alcohol at social gatherings but denies any use of tobacco or other substances. Sexuality: - The patient identifies as heterosexual and is currently in a monogamous relationship. They use contraception consistently and have no sexual health concerns. Suicide/Depression: - The patient reports occasional feelings of sadness but denies any history of self-harm or suicidal thoughts. They have a supportive mental health history with regular counseling sessions. Safety: - The patient feels safe at home and school. There are no reported experiences of violence or abuse.