Blank Psychotherapy Appointments Doctor Note

Patient Information

Name: (Enter the full name of the patient.)
Date of Birth: (Provide the patient’s date of birth in MM/DD/YYYY format.)
Patient ID: (Include a unique identification number for the patient, if applicable.)
Date of Appointment: (Record the date of the session in MM/DD/YYYY format.)
Therapist Name: (Write the name of the therapist conducting the session.)
Therapist License Number: (Provide the therapist's license number for verification.)
Contact Information: (Include the therapist's contact number or email for follow-up.)

Duration of Session: ______________ minutes
(Indicate the length of the session in minutes.)
Session Type: (Individual / Group / Family)
(Specify the type of therapy session conducted.)
Location: (Note the location of the session, or specify if it was conducted online.)
Telehealth (if applicable): (Yes / No)
(Mark whether the session was conducted via telehealth.)

Chief Complaint:
(Summarize the main issue the patient is seeking help for.)
History of Presenting Concern:
(Provide a brief history of the current issue, including onset and duration.)
Relevant Past Medical History:
(Include any significant past medical or psychological history that may be relevant.)

Appearance: (Describe the patient's physical appearance, grooming, and attire.)
Mood: (Document the patient's reported mood (e.g., depressed, anxious, stable).)
Affect: (Describe the emotional expression of the patient during the session.)
Thought Process: (Note if the patient's thoughts were coherent, logical, disorganized, etc.)
Thought Content: (Record any significant thoughts, including delusions or obsessions.)
Insight: (Assess the patient’s understanding of their condition and treatment.)
Judgment: (Evaluate the patient’s decision-making abilities and risk awareness.)

Techniques Used: (e.g., CBT, DBT, Mindfulness)
(List the therapeutic techniques applied during the session.)
Topics Discussed:
(Summarize the main topics or issues discussed during the session.)
Patient Engagement Level: (Low / Moderate / High)
(Assess and note the patient’s level of engagement in the session.)

Focus Areas for the Next Session:
(Identify key areas to focus on during the next appointment.)
Homework Assignments:
(Document any assignments given to the patient for practice between sessions.)
Next Appointment Date: (Schedule and note the date and time of the next session.)

Additional Notes: (Include any other relevant information or observations not covered above.)

Therapist Signature: (The therapist should sign and date the note to confirm its accuracy.)