Treatment Note Templates

Intake Evaluation Note Template

This therapist completed intake evaluation today. This therapist worked to assess Johnny’s level of functioning throughout this session. This therapist utilized rapport building strategies to establish and enhance Johnny’s engagement throughout this session. This clinician utilized active listening strategies, working to validate Johnny’s input. Johnny presented engaged with some anxiety per their report. This clinician determined initial diagnostic assessment and is to continue assessing further next session.

Ongoing Therapy Note Template Subjective:
Johnny presented today for therapy session. Johnny noted concerns with anxiety and insomnia since previous session, following an argument with paramour. Johnny reported “I’ve felt all over the place this week.” Johnny reports compliance with prescribed medication and denies suicidal ideation.

Objective:
This clinician worked to assess Johnny’s functioning throughout this session. Johnny worked to process trigger to spike in anxiety symptoms following argument with paramour. This clinician utilized CBT strategies, assisting Johnny reflect on trigger and response further. This clinician utilized active listening strategies, working to nurture client engagement throughout. Johnny worked to enhance understanding of himself and functioning today.

Assessment:

Per Johnny’s report and this clinician’s observations, Johnny’s average anxiety symptoms have increased this past week but continues to meet the criteria for Generalized Anxiety Disorder (GAD).

Plan:

Johnny to continue the current plan of care. Johnny to continue practicing a minimum of 3 learned coping skills per day to assist managing symptoms of GAD. Johnny committed to practicing a new learned coping skill (journal writing).