Session Info

Date:

CPT code (90791 / 90792 / other):

Session duration (min):

Modality (in-person / telehealth / hybrid):

Consent acknowledged:

Intake Narrative

Referral source, CC, HPI, symptom history, prior treatment, current supports, and barriers.

Risk screen, substance use, sleep, appetite, trauma exposure, medical issues, and medications.

Initial Plan

Dx impression, case formulation, treatment focus, frequency, outcome measures, referrals, and homework.

Risk/Safety Review

Complete a C-SSRS / SAFE-T from the patient's current responses when suicidal ideation, self-harm, acute risk, or default risk placeholders are present.

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

Brief MSE

Mood / affect:

Thought content:

Cognition:

Insight / judgment:

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

Intake Narrative

Initial Plan

Risk/Safety Review

Diagnosis

Diagnosis Snapshot

PHQ-9

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

GAD-7

Details

Responses

Brief MSE

Plan and Follow-Up

Counseling - Therapy Intake Note

Preview