Notes Templates
What it’s used for
These are templates you can use for writing your case notes. These templates can be used for
any case notes you write, including sessions, consultations or other notes.
How it works
If you use paper records, just choose the template you like, print and write! If you use electronic
records and you’re able to create your own template, choose what you prefer and add the
clinical information to the editable template.
How to personalize it
A nice way to personalize your notes is to include check boxes for things you find yourself
writing over and over again. However, each clinician’s check boxes will be different. What I
recommend is that you use one of these templates consistently for about six months. After that
time do a review of your notes and circle the phrases or words you find yourself writing multiple
times across clients. Those are the check boxes you should include in your new and improved
template!
Another option is to take bits and pieces of the templates. I’ve worked with clinicians who chose
to take out pieces of DAP and SOAP to create their own acronym. I’ve also worked with
clinicians who thought one template was great for intake sessions but another was best for
ongoing sessions. Your options are endless.
Case Note
Maelisa Hall, PsyD
Licensed Psychologist #25295
123 Main Street Long Beach CA
(999)888-7777
drmaelisahall@gmail.com
Client Name:________________________________________________________________
Date:_______________
Time:_______________
Session Type (CPT):_______________
Session#________
Insurance Status:_________________________
Data
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Assessment
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Clinician Signature:______________________________________________
Case Note
Maelisa Hall, PsyD
Licensed Psychologist #25295
123 Main Street Long Beach CA
(999)888-7777
drmaelisahall@gmail.com
Client Name:________________________________________________________________
Date:_______________
Time:_______________
Session Type (CPT):_______________
Session#________
Insurance Status:_________________________
Goal
___________________________________________________________________________
___________________________________________________________________________
Intervention
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Response
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Clinician Signature:______________________________________________
Case Note
Maelisa Hall, PsyD
Licensed Psychologist #25295
123 Main Street Long Beach CA
(999)888-7777
drmaelisahall@gmail.com
Client Name:________________________________________________________________
Date:_______________
Time:_______________
Session Type (CPT):_______________
Session#________
Insurance Status:_________________________
Problem
___________________________________________________________________________
___________________________________________________________________________
Assessment
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Intervention
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Clinician Signature:______________________________________________
Case Note
Maelisa Hall, PsyD
Licensed Psychologist #25295
123 Main Street Long Beach CA
(999)888-7777
drmaelisahall@gmail.com
Client Name:________________________________________________________________
Date:_______________
Time:_______________
Session Type (CPT):_______________
Session#________
Insurance Status:_________________________
Subjective
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Objective
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Assessment
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Clinician Signature:______________________________________________
Case Note
Maelisa Hall, PsyD
Licensed Psychologist #25295
123 Main Street Long Beach CA
(999)888-7777
drmaelisahall@gmail.com
Client Name:________________________________________________________________
Date:_______________
Time:_______________
Session Type (CPT):_______________
Session#________
Insurance Status:_________________________
Session Content
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Plan
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Clinician Signature:______________________________________________