CLIENT VISIT NOTES
Client Name:
Date:
DX:
Session #:
CPT Code:
Present in Session:
Client's Presenting Concerns:
Symptoms:
Note severity and whether targeted in session for those symptoms present.
Mild
Moderate
Severe
Targeted
Depressed Mood
Insomnia
Hypersomnia
Weight Loss/Gain
Psychomotor Agitation/Retardation
Fatigue / Loss of Energy
Difficulty Concentrating
Indecisiveness
Hopelessness
Low Self-Esteem
Recurring Thoughts of Death
Suicidal Ideation
Suicide Plan
Suicide Attempt
Self-Injurious Behavior
Homicidal Ideation
Anxiety / Worry
Panic Attacks
Phobia
Obsessive Thoughts
Compulsive Behavior
Irritability
Angry Outbursts
Hypomania / Mood Swings
Relationship Problems
Withdrawal / Isolation
Impaired Social Skills
Substance Abuse
Problems with Work Performance
Problems with Academic Performance
ADHD (Inattentive/Hyperactive)
Perceptual Disturbance
Memory Disturbance
Impaired Judgement
Restricting Food Intake
Overeating
Binge / Purge
Medical Concerns
Exaggerated Startle Response
Restricted Range of Affect
Restlessness or Feeling Keyed Up
Hypervigilance
Muscle Tension
Recurrent Distressing Recollections / Dreams
Anhedonia
Somatic Complaints
Other:
Notes:
Medication(s)/Dosage(s):
Treatment Plan:
Homework:
Treatment(s) Utilized:
Assessment
Behavioral Approach
Cognitive Restructuring
Collateral Contact
Couples / Family
DBT Therapy
Desensitization
Emotional Processing
Individual Therapy
Insight-Oriented
Play Therapy
Psycho-Education
Skills Training
Solution Focused
Stress Management
Other:
Next Appt
Clinician Signature