Clinician Name *

Anxious / Depressive Symptoms Ratings

Levels of Anxious Symptoms (0-10)

Levels of Depressive Symptoms (0-10)

Diagnostic Evaluation

Presenting Problems: *

What is the client's Diagnosis & what are the Signs and Symptoms (DSM-V-TR based) resulting in impairment(s): (Include current examples for treatment planning, e.g., social, occupational, affective, cognitive, physical) *

How are symptoms currently impacting functioning? *

Treatment Plan

When was this Treatment Plan Established or Revisited? (EXPIRES 90-DAYS) *

Goal of Treatment (Tx Plan goals): GOAL/ OBJECTIVE/ INTERVENTIONS/FREQUENCY *

by session Signs

Treatment Plan Progress *

Treatment Recommendation *

Continue Current Therapeutic Focus
Change Treatment Goals or Objectives
Terminate Treatment

Session Note Details

Data / Session Focus

Interventions *

Progress Note: (issues presented in session by pt; therapist observations of symptoms; interventions utilized; response from patient; plan for future sessions)

Medical Necessity Factors Influencing Length a/o Frequency of sessions to avoid higher levels of care or longer/ more frequent outpatient sessions *

Assessments, Tools, Screeners, Etc given and results

PHQ-9 Score:

GAD-7 Score:

CAGE Responses:

SBQ Risk Level:

ACE Score:

PTSD – Checklist Answers

ADHD Screening Answers

Crisis Protocol: Suicide-Homicidal Assessment

Other; explain

Mental Status Exam

Attention/Cognition *

Affect *

Mood *

Appearance *

Motor Activity *

Thought Process *

Delusions *

Memory *

Insight *

Judgement *

Orientation *

Speech

Medication Compliance & Status

Medications *

Medication Compliance *

Yes
No
Referral Made
N/A

Substance Use Assessment

Substance Use *

Yes
None
Denied Use
Did not Assess

Substance Use Assessment & Relevant Content *

Safety Issues / Risk Assessment

Date / Time

Date

Time

Signature

Progress Note Training