Not sure where to start? Want to see how other folks are using custom templates?
Here are a few examples to spark ideas -- each one includes a name, a quick description, and the section names you'd enter when creating the template.
Remember: when you're creating a template, you're only entering the section names -- no formatting, descriptions, or extra explanation. Keep it clean and simple, one section per line.
Intake Assessment
Description: Documentation after a client's first session to capture background info, presenting concerns, and initial treatment goals.
Section Names:
- Presenting Concerns
- Mental Health History
- Medical History
- Current Symptoms
- Strengths and Supports
- Treatment Goals
Supervision Note
Description: A note to document supervision sessions with a supervisee.
Section Names:
- Date and Time
- Topics Discussed
- Ethical Considerations
- Feedback Provided
- Plan Moving Forward
Couples Therapy Note
Description: A progress note for sessions with couples -- noting relationship dynamics and joint goals.
Section Names:
- Presenting Concerns
- Partner Dynamics
- Session Focus
- Therapist Interventions
- Client Response
- Homework Assigned
Termination Summary
Description: A short summary when therapy comes to a close (either planned or unplanned).
Section Names:
- Reason for Termination
- Summary of Progress
- Remaining Challenges
- Client Feedback
- Referrals or Follow-Up
Group Session Note
Description: A note after facilitating a group session, to track themes and individual participation.
Section Names:
- Group Topic
- Participants Present
- Themes Discussed
- Client Contributions
- Facilitator Observations
- Next Group Topic
Play Therapy Note
Description: A progress note after a session working with children using play therapy techniques.
Section Names:
- Presenting Concern
- Play Themes Observed
- Child's Affect and Behavior
- Therapeutic Techniques Used
- Parent Feedback
- Plan for Next Session
EMDR Session Note
Description: A simple but structured way to document sessions involving EMDR.
Section Names:
- Phase of Treatment
- Target Memory or Event
- Client Response
- Bilateral Stimulation Used
- Insights or Shifts Observed
- Next Target or Plan
Progress Note with a Twist
Description: A lightly customized alternative to a standard SOAP or DAP note. More room for your personal style.
Section Names:
- What Brought Them In
- What Happened in Session
- Therapist's Take
- What Happens Next
Want to try one of these? You can copy and paste the section names straight into the template editor and use the description if you'd like. Then tweak away until it fits your requirements and workflow.
That's a wrap. We hope these examples and ideas help you create your own custom templates.
And should you ever need help, we're just an email away: jon@quilltherapynotes.com
