SIMPLE Note Example: Navigating Gender Identity

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Client attended a 60-minute session at the office today. Client appeared a little nervous and disclosed they have been questioning their gender identity, expressing uncertainty with 'I don’t know where I fit in.' The session focused on their confusion regarding self-expression and the impact of their family's traditional expectations, contributing to feelings of isolation and anxiety. The fear of rejection was identified as a significant concern for the client. Interventions included discussing the journey of self-acceptance and the therapeutic value of journaling to track moments of comfort in their identity. The client was receptive to the idea of journaling and exploring safe communities for identity expression. By the end of the session, the client expressed a sense of relief and appeared to have a clearer direction for addressing their concerns. A follow-up session is scheduled in two weeks to review their progress with journaling and ongoing feelings.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over.

We had a 60-minute session today at the office. Client came in looking a little nervous, said they’ve been questioning their gender identity for a while now, and it’s been really weighing on them. They said quote 'I don’t know where I fit in' unquote. We started talking about how they feel really confused about expressing themselves and how family expectations have been making it worse. They mentioned that their family’s pretty traditional, and it’s making them feel stuck, like they can’t be who they really are. They talked about how they’ve been feeling kinda isolated and anxious because they don’t know how people in their life will react. It was pretty heavy.

We dove into some of those fears, and I could tell that the fear of rejection has been a big thing for them. We talked about how self-acceptance is not something that happens overnight, and it’s a process. They said quote 'I just want to feel like I’m being real, not hiding all the time' unquote. I suggested they start keeping a journal to write down their feelings and maybe even track moments where they felt the most comfortable in their identity—just to reflect. They seemed pretty open to that idea. We also talked about finding spaces or communities where they feel safe to explore their identity without judgment, because that could help ease some of this anxiety.

They seemed kinda relieved by the end of the session, like they finally have a direction to start working through this. We’re gonna meet again in two weeks to see how they’re feeling and how the journaling is going.

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More About SIMPLE Notes:

From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about SIMPLE notes.