Blank Psychotherapy Appointments Doctor Note

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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.)

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Session Information

• 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.)

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Presenting Concerns

• 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.)

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Mental Status Examination

• 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.)

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Interventions Provided

• 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.)

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Plan for the Next 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.)

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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.)

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