CLINICAL NOTE TOOL
INTERVENTION LIBRARY
SESSION DETAILS
Session Type:
In-Person
Telehealth (SimplePractice)
Pronoun:
they/their
she/her
he/him
Start Time:
End Time:
SESSION PREAMBLE
SESSION SUMMARY
THERAPEUTIC INTERVENTIONS
CLIENT RESPONSE
ASSESSMENT
RISK ASSESSMENT
Suicide Risk:
Client denied suicidal ideation.
Passive suicidal ideation without plan.
Active suicidal ideation with plan.
Further assessment indicated.
Self-Harm Risk:
Client denied thoughts or behaviors of self-harm.
History of self-harm; no current urges.
Current urges reported.
Current self-harm behavior reported.
Homicidality:
Client denied homicidal ideation.
Passive homicidal thoughts.
Active homicidal ideation.
Substance Use Risk:
No current concerns reported.
Mild concern.
Moderate concern.
High concern.
MSE
Appearance:
Well-groomed.
Casually dressed.
Disheveled.
Behavior:
Cooperative.
Guarded.
Agitated.
Calm.
Speech:
Normal rate and volume.
Pressured.
Slow.
Soft.
Mood:
Euthymic.
Anxious.
Depressed.
Irritable.
Affect:
Congruent with mood.
Restricted.
Flat.
Labile.
Thought Content:
Reality-based.
No delusional content observed.
Obsessive thought content.
Ruminative thought content.
Thought Process:
Linear and goal-directed.
Circumstantial.
Tangential.
Flight of ideas.
Perception:
No perceptual disturbances reported or observed.
Auditory hallucinations reported.
Visual hallucinations reported.
Cognition:
Alert and oriented ×4.
Mild memory impairment.
Distractible.
Insight:
Good.
Fair.
Limited.
Poor.
Judgment:
Good.
Fair.
Limited.
Poor.
PLAN
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