Session Info

Date:

CPT / E&M code:

Session duration (min):

Modality (in-person / telehealth / phone):

Attendance (client / parent / collateral / interpreter):

Consent acknowledged:

Evaluation

Presenting symptoms, onset/course, functional impairment, prior episodes, psychiatric history, medical history, medications, and substances.

Safety, abuse/neglect, trauma, family history, culture, supports, strengths, and preferences.

Recommendations

Dx impression, LOC, treatment modality, frequency, outcome measures, referrals, and care-coordination tasks.

Risk/Safety Review

Complete the embedded C-SSRS when suicidal ideation, self-harm, acute risk, or unclear safety status is present; use SAFE-T for full triage when needed.

Assessment Status: Not assessed

Display: Working diagnosis / clinical impression

0/27 Score

0 of 9 Answered

minimal 0-4 minimal · 5-9 mild · 10-14 moderate · 15-19 mod-severe · 20-27 severe

Little Interest or Pleasure in Doing Things

0123

Unanswered

Feeling Down, Depressed, or Hopeless

0123

Unanswered

Trouble Falling/Staying Asleep, or Sleeping Too Much

0123

Unanswered

Feeling Tired or Having Little Energy

0123

Unanswered

Poor Appetite or Overeating

0123

Unanswered

Feeling Bad About Yourself — or That You Are a Failure

0123

Unanswered

Trouble Concentrating on Things

0123

Unanswered

Moving or Speaking Slowly, or Restless/Fidgety

0123

Unanswered

Thoughts of Being Better off Dead or Hurting Yourself

0123

Unanswered

Variant: adult
Item Responses

Not Provided/21 Score

Feeling Nervous, Anxious, or on Edge

0123

Unanswered

Not Being Able to Stop or Control Worrying

0123

Unanswered

Worrying Too Much About Different Things

0123

Unanswered

Trouble Relaxing

0123

Unanswered

Being So Restless That It Is Hard to Sit Still

0123

Unanswered

Becoming Easily Annoyed or Irritable

0123

Unanswered

Feeling Afraid as if Something Awful Might Happen

0123

Unanswered

Mental Status Exam

Appearance:

Behavior / cooperation:

Speech:

Mood:

Affect:

Thought process:

Thought content (SI / HI / paranoia / AH / VH):

Perception:

Cognition / orientation:

Insight:

Judgment:

Suicidal ideation (current / past / none; plan or intent if present):

Homicidal ideation (current / past / none):

Cognitive screen (MoCA / MMSE / orientation x3 result):

Level of care (ASAM / LOCUS / clinical judgment):

Modality:

Frequency:

Measures (PHQ-9 / GAD-7 / other):

Referrals:

Informed consent reviewed and signed.

Releases of information (PCP, prior provider, family, school) signed.

Substance use screened - consider AUDIT-C template if positive.

Safety disposition, protective factors, and follow-up actions documented after risk review.

Plan and Follow-Up

Focus	Documentation
Assessment	Clinical impression, diagnostic formulation, severity, strengths, barriers, and uncertainty. Clinical impression: Differential / rule-outs: Strengths and barriers:
Initial plan	Planned modality, frequency, measures, referrals, coordination, and patient goals. Treatment focus: Frequency / measures: Referrals / coordination:
Risk / follow-up	Risk status, safety actions when indicated, next appointment, and items to complete before then. Risk status: Follow-up interval: Before next visit:

Focus

Documentation

Assessment

Clinical impression, diagnostic formulation, severity, strengths, barriers, and uncertainty.

Clinical impression:

Differential / rule-outs:

Strengths and barriers:

Initial plan

Planned modality, frequency, measures, referrals, coordination, and patient goals.

Treatment focus:

Frequency / measures:

Referrals / coordination:

Risk / follow-up

Risk status, safety actions when indicated, next appointment, and items to complete before then.

Risk status:

Follow-up interval:

Before next visit:

Session Info

Evaluation

Recommendations

Risk/Safety Review

C-SSRS

Assessment Status

Diagnosis

Diagnosis Snapshot

PHQ-9

Over the past 2 weeks, how often have you been bothered by...

GAD-7

Details

Responses

Mental Status Exam

Plan and Follow-Up

Counseling - Behavioral Health Initial Evaluation

Preview