Behavioral Health Note Templates & Examples

Free, copy-ready templates for the notes and documents healthcare and behavioral health professionals actually write. Every template includes a plain-language definition, the structure section by section, a complete fictional sample, and the compliance details that matter, reviewed by the BastionGPT Clinical Advisory Board.

The library covers 100+ document types and new templates publish routinely. Don't see the one you need? Contact our support team and we'll prioritize it.
A complete sample

Every page includes a full fictional example at realistic length, plus a blank structure you can copy into your own workflow.

Compliance built in

Psychotherapy-note boundaries, payer and audit expectations, and privacy rules, explained for each document type.

US, Canada, and Australia

Key templates include a jurisdiction table covering naming, governing bodies, and billing context in all three countries.

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Session & Progress NotesIntake & Clinical AssessmentsTreatment PlanningRisk & SafetyEvaluation ReportsTest Write-Up GuidesCare CoordinationConsent & PrivacyBilling & Practice OpsWork, School & Disability

Session & Progress Notes

The recurring note formats clinicians write after every session: SOAP, DAP, BIRP, PIE, and the specialized individual, group, couples, crisis, and telehealth session notes.

BIRP Note

A BIRP note is a four-part progress note format that organizes a session into Behavior, Intervention, Response, and Plan. Its signature strength is forcing the intervention-and-response thread onto the page, which is exactly what payer reviewers read for. A typical BIRP note runs 150 to 300 words.

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Canada Telepsychology & Virtual Care Note

A Canadian telepsychology and virtual care note is an ordinary progress note with telepresence elements added: session modality, the client's physical location, consent to virtual care, an emergency plan naming local resources, and a technology-failure fallback. Canadian psychologists and psychotherapists write one after every video or telephone session. No college mandates a template; expectations come from provincial standards and the CPA telepsychology guidelines. Most run 200 to 400 words.

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Crisis Psychotherapy Note

A crisis psychotherapy note documents an encounter where psychotherapy addressed an acute crisis: the precipitating event, urgent assessment, mental status, risk findings, interventions, client response, and disposition. Therapists, psychologists, counselors, and clinical social workers write one after crisis encounters in office, telehealth, or community settings. In the US it supports the time-based crisis codes 90839 and 90840. A typical crisis note runs 250 to 700 words.

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DAP Note

A DAP note is a three-part progress note format that organizes a therapy session into Data, Assessment, and Plan. It merges SOAP's Subjective and Objective material into a single Data section, which suits the more qualitative flow of psychotherapy documentation. A typical therapy DAP note runs 150 to 300 words.

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Family & Couples Therapy Note

A family and couples therapy note is the clinical record of a conjoint psychotherapy session, one where partners or family members attend together. It documents who attended, the relational patterns addressed, the interventions, each person's response, and progress toward treatment goals. Most run 200 to 500 words. Unlike an individual note, it must serve several people's privacy rights inside one story.

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Group Therapy Note

A group therapy note is the progress note a clinician writes for each member of a group psychotherapy session. It pairs a brief group-level summary of the session's topic and interventions with individualized documentation of that member's participation, response, and progress. Group therapists write one note per member after every session. A typical note runs 100 to 250 words per member.

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Individual Therapy Session Note

An individual therapy session note is the clinical record of one one-on-one psychotherapy session: what was addressed, the interventions used, the client's response, current risk, and the plan for the next session. Therapists, psychologists, counselors, and clinical social workers write one after every session, in SOAP, DAP, BIRP, or narrative form. Most run 150 to 350 words.

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Narrative Progress Note

A narrative progress note is a free-text progress note that documents a therapy session in flowing prose instead of the labeled sections of SOAP or DAP. Therapists use it when a session's chronology and reasoning matter more than a template, and it is fully compliant as long as the required content is present. Most narrative notes run 150 to 500 words.

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PIE Note

A PIE note is a three-part progress note format that organizes a session into Problem, Intervention, and Evaluation. Each entry hangs off a numbered problem from the client's problem list; there is no separate assessment or plan section, so interpretation and next steps live inside the entry. Behavioral health and nursing-adjacent teams use it for problem-focused charting. A typical PIE note runs 100 to 250 words.

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Psychotherapy Progress Note

A psychotherapy progress note is the session-by-session record of psychotherapy in the standard clinical chart: how the client presented, the interventions used, the response, and the plan. Despite the similar name, it is legally distinct from HIPAA's separately kept psychotherapy notes. Most therapy progress notes run 100 to 350 words.

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SOAP Note

A SOAP note is a progress note format that organizes a clinical encounter into four sections: Subjective, Objective, Assessment, and Plan. Therapists, psychologists, and integrated care teams use SOAP notes to document sessions in a structure that other providers, payers, and auditors can read quickly. A typical therapy SOAP note runs 150 to 350 words.

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Telehealth Psychotherapy Note

A telehealth psychotherapy note is the progress note for a therapy session delivered by video or phone. It records everything a standard session note does, plus the telehealth layer: modality, client location, provider location, consent, technology issues, and a session-specific emergency plan. Therapists, psychologists, and counselors write one after every virtual session. A typical telehealth note runs 150 to 400 words.

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Intake & Clinical Assessments

First-contact and interview-based assessment documents, from the intake note and psychiatric diagnostic evaluation to the biopsychosocial, trauma, and culturally responsive assessments.

Aboriginal & Torres Strait Islander Culturally Safe Assessment

A culturally safe assessment is a clinical assessment conducted and documented so that Aboriginal and Torres Strait Islander clients experience care as culturally safe, a judgment that belongs to the client, not the clinician. Australian psychologists, GPs, and multidisciplinary teams apply the standard to intake, mental health, and cognitive assessment. No law prescribes a form; the record evidences a culturally safe process.

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Biopsychosocial Assessment

A biopsychosocial assessment is the comprehensive intake document that examines a client's presenting problem across biological, psychological, and social domains and ties them together in an integrated summary. Therapists, clinical social workers, counselors, and case managers complete one at admission to treatment, and it anchors the diagnosis, level of care, and treatment plan. A typical biopsychosocial assessment runs 600 to 1,500 words.

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Child & Adolescent Developmental Assessment

A child and adolescent developmental assessment documents a child's developmental history and milestone attainment across motor, language, cognitive, social-emotional, and adaptive domains, then ties the findings to eligibility or diagnosis. Child psychologists, developmental-behavioral teams, and early intervention programs complete one when a screen raises concern or a school, pediatric, or Part C referral asks what is going on. Most run 500 to 1,500 words.

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Cultural Formulation Interview (CFI) Intake

A cultural formulation interview (CFI) intake documents what the 16-question CFI from DSM-5-TR elicits: the client's own definition of the problem, explanatory model, stressors and supports, cultural identity, and preferences for care. Psychologists, therapists, and psychiatrists fold it into initial evaluations when cultural context shapes diagnosis or engagement. The interview takes about 20 minutes; the documented section usually runs 200 to 500 words.

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Eating Disorder Assessment

An eating disorder assessment is a structured intake evaluation that combines a validated screener such as the SCOFF or EDE-Q, DSM-5-TR criterion mapping, eating and weight history, and a medical-risk appraisal with a level-of-care rationale. Therapists, psychologists, and counselors complete it at intake, coordinating with medical and nutrition colleagues. Most run 400 to 1,000 words.

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General Risk Screening Note

A mental health risk screening note documents a brief, standardized screen for suicide, violence, abuse, substance use, and psychosis risk: the instrument used, the result for each domain, a positive or negative determination, and the follow-up action. Therapists and intake staff complete it at intake or when concerns arise, often inside the intake or progress note. Most run 50 to 150 words.

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Indigenous & First Nations Wellness Assessment Addendum

An Indigenous wellness assessment addendum is a culturally grounded section added to a standard mental health intake for First Nations, Inuit, Métis, American Indian/Alaska Native, or Aboriginal and Torres Strait Islander clients. It documents strengths, family and community connections, language and culture, spiritual factors, and community supports. No payer or regulator mandates the format; it reflects wellness frameworks such as the FNMWC. Most run 300 to 600 words.

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Intake Note

A therapy intake note documents a new client's first clinical session: presenting problem, relevant history, a risk screen, mental status observations, an initial clinical impression, and the starting plan. Therapists, counselors, and psychologists write one at the start of each new episode of care, and the rest of the chart builds on it. A typical intake note runs 300 to 900 words.

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Mental Status Exam (MSE) Note

A mental status exam (MSE) is the clinician's structured description of how a client presents at one point in time: appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. Psychologists, psychiatrists, therapists, and medical teams record a complete MSE at intake or diagnostic evaluation and briefer focused versions afterward. Most written MSEs run 80 to 250 words.

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Parent & Caregiver Collateral Note

A parent and caregiver collateral note documents information a clinician gathers from someone other than the client, such as a parent, guardian, or caregiver, and what the clinician did with it. Child and adolescent therapists write one after any substantive caregiver contact. The note lives in the client's chart, attributes every statement to its source, and typically runs 100 to 300 words.

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Psychiatric Diagnostic Evaluation

A psychiatric diagnostic evaluation is the comprehensive initial assessment that establishes a mental health diagnosis and treatment plan: psychiatric, medical, family, and social history, a mental status exam, and a risk assessment. Psychiatrists, psychologists, therapists, and psychiatric nurse practitioners complete one at the start of care; US payers bill it as CPT 90791, or 90792 when medical services are included. A typical evaluation runs 500 to 1,200 words.

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School & Teacher Collateral Note

A school and teacher collateral contact note is a therapist's chart record of a conversation with a teacher, school counselor, or other school staff member about a minor client. Child and adolescent clinicians write one after each school contact to capture classroom observations and connect them to the treatment plan. Most run 100 to 300 words.

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Substance Use Assessment

A substance use assessment is the comprehensive clinical evaluation that establishes whether a substance use disorder is present, how severe it is, and which level of care fits. Behavioral health clinicians and alcohol and drug counselors complete one at entry to treatment, usually organized around the six ASAM Criteria dimensions. A typical substance use assessment runs 400 to 1,200 words.

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Trauma Assessment

A trauma assessment is a structured clinical evaluation of a client's trauma history, current trauma- and stressor-related symptoms, dissociation, and immediate safety. Psychologists, therapists, and counselors complete one at intake, or when trauma surfaces during treatment, usually pairing a clinical interview with a validated screen such as the PCL-5 or PC-PTSD-5. A typical trauma assessment runs 300 to 900 words.

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Treatment Planning

Plans, reviews, and formulations that set treatment goals and tie every session back to medical necessity.

Better Access Mental Health Treatment Plan Referral

A Mental Health Treatment Plan is the document an Australian GP or prescribed medical practitioner prepares under Better Access to assess a diagnosed mental disorder and support Medicare-rebated psychology sessions. A separate signed and dated referral, not the plan, authorises those sessions. GPs prepare both; the psychologist holds the referral and reports back after each course. Most plan-and-referral pairs run 600 to 1,200 words.

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Case Formulation Note

A case formulation note (also called a case conceptualization) is the working hypothesis of a case: how predisposing, precipitating, perpetuating, and protective factors fit together to produce the presenting problem, and what that means for treatment. It is written at intake and revised at major reviews rather than every session. Most run one to two pages, and no law or payer prescribes its format.

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Outcome Measure Review Note

An outcome measure review note is the documentation entry of measurement-based care: it records which standardized instrument was administered, the score, the change from baseline, the clinical interpretation, the discussion with the client, and the treatment decision that follows. Therapists, psychologists, and collaborative care teams write one each time a measure like the PHQ-9 or GAD-7 is given. Most run 75 to 300 words beside a score flowsheet.

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Relapse Prevention Plan

A relapse prevention plan is a written plan a clinician and client build together that names the client's triggers, early warning signs, coping strategies, support contacts, and the steps to take after a lapse. Substance use and mental health clinicians write one mid-treatment or before step-down, usually inside the treatment plan. Most run 300 to 800 words, built in a 20 to 45 minute session.

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Treatment Plan

A mental health treatment plan is the roadmap document for a course of therapy: diagnoses, presenting problems, measurable goals and objectives, the interventions that will address them, and how often care happens. Unlike a progress note, it is future-focused and spans many sessions. Most run one to three pages and are reviewed on a set schedule.

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Treatment Plan Review & Update

A treatment plan review is the periodic note that measures progress against each goal in the active mental health treatment plan, records barriers and new clinical information, and ends in a decision: continue the plan unchanged or update it. Clinicians complete one on their program's cadence and whenever the clinical picture changes. Most run 150 to 500 words.

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Risk & Safety

Documentation for suicide and violence risk assessment, self-harm, safety planning, and mandated reporting duties.

Mandated Reporting & Duty-to-Protect Documentation

Mandated reporting and duty-to-protect documentation is the chart record a clinician creates when reporting suspected child or elder abuse, or acting on a client's threat of serious violence against an identifiable person. It captures the facts observed, the legal basis, who was notified and when, and the clinical reasoning. State law mandates the report itself; the note is the clinician's proof the duty was met.

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Safety Plan

A safety plan is a brief document a clinician and client build together during or after a suicidal crisis: personal warning signs, coping strategies, people and places that help, professional and crisis contacts, and steps to make the environment safer. The client keeps a copy. Most follow the six-step Stanley-Brown format, often with an optional reasons-for-living step, and take 20 to 45 minutes to complete together.

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Self-Harm (NSSI) Assessment

A self-harm assessment, also called an NSSI assessment, is the clinical documentation of how a clinician evaluated non-suicidal self-injury: the behavior's history and severity, the suicide risk screen that separates it from suicidal self-injury, its function, and the risk formulation with the response. Clinicians document one when self-injury is disclosed or discovered. Most run 300 to 800 words, and no regulator prescribes a format.

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Suicide Risk Assessment

A suicide risk assessment is the clinical documentation of how a clinician evaluated a client's suicide risk: the inquiry into ideation, plan, intent, and access to means, the risk and protective factors weighed, a risk formulation, and the actions taken. Mental health professionals document one at intake, when risk indicators emerge, and after a crisis. Most run 200 to 800 words, and the formulation must support the disposition.

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Violence & Homicide Risk Assessment

A violence and homicide risk assessment is the clinical record of how a clinician evaluated a client's risk of harm to others: the threat and its context, target identifiability, intent and access to means, risk and protective factors, a formulation, and the protective actions taken or reasonably ruled out. Clinicians document one when a client threatens an identifiable person or homicidal ideation emerges. Most run 300 to 800 words.

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Psychological Evaluation Reports

Complete report structures psychologists write after testing: psychological, neuropsychological, psychoeducational, ADHD, autism, and forensic evaluations.

ADHD Evaluation Report

An ADHD evaluation report is the written product of a diagnostic assessment for attention-deficit/hyperactivity disorder. It integrates the referral question, history, observations, and multi-informant rating scales into a DSM-5-TR criteria mapping, a differential, a diagnosis, and recommendations. Psychologists, psychiatrists, pediatricians, and primary care prescribers write them for children and adults. Most run 3 to 10 pages and are shared with families, schools, and prescribers.

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Autism Spectrum Evaluation Report

An autism spectrum evaluation report is the written product of a diagnostic evaluation for autism spectrum disorder. It integrates developmental history, caregiver interview, direct observation, and standardized instruments into a DSM-5-TR criteria mapping, a diagnosis with severity and support levels, and functional recommendations. Psychologists, developmental pediatricians, and multidisciplinary teams write them for children and adults. Most run 4 to 15 pages and feed schools, payers, and disability programs.

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Capacity & Competency Evaluation

A capacity evaluation is a clinician's structured assessment of whether a person can make a specific decision at a specific time, such as consenting to treatment, managing finances, or making a will. Psychologists, psychiatrists, and physicians write them for treating teams, courts, and tribunals. Capacity is the clinical judgment; competency is the court's legal determination. Most reports run 2 to 8 pages.

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Fitness-for-Duty Evaluation

A fitness-for-duty evaluation (FFDE) is a formal psychological examination of an employee, ordered by the employer when objective evidence suggests a mental health condition may be impairing safe or effective job performance. Psychologists and psychiatrists retained by the employer conduct them; the employer, not the examinee, is the client. Most reports run 2 to 8 pages and answer a specific referral question.

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Forensic Psychological Evaluation Report

A forensic psychological evaluation report is the written product of an evaluation conducted to answer a legal question, such as competency to stand trial, criminal responsibility, or parenting capacity. A court or attorney is the client, the person examined is an evaluee rather than a patient, and confidentiality is limited. Psychologists and psychiatrists write them; length varies by matter, and no statute sets a maximum.

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NDIS Functional Capacity Assessment Report

An NDIS functional capacity assessment report is an allied health report documenting how a person's disability affects everyday functioning across six domains: communication, social interaction, learning, mobility, self-care and self-management. It provides evidence for NDIS access and planning decisions and recommends supports with frequency and duration. Occupational therapists, psychologists and other qualified professionals write them. Most run 15 to 30 pages after 1 to 10 hours of assessment.

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NDIS Plan Reassessment & Progress Report

An NDIS progress report, called a plan reassessment report in current NDIA language, is the document a treating allied health provider writes toward the end of a participant's plan period. It summarises the supports delivered, evidences progress against a functional baseline using named outcome measures, and justifies recommended supports for the next plan against the NDIS reasonable and necessary criteria. Most run 3 to 6 pages.

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Neuropsychological Evaluation Report

A neuropsychological evaluation report is the written product of neuropsychological testing: it integrates the referral question, history, behavioral observations, and standardized cognitive test scores into a domain-by-domain interpretation, a diagnosis, and functional recommendations. Neuropsychologists write one after evaluating conditions such as brain injury, dementia, ADHD, or epilepsy, addressed to the referring physician and increasingly read by the patient. Most clinical reports run 5 to 20 pages.

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Psychoeducational Evaluation Report

A psychoeducational evaluation report is the written product of an assessment that integrates cognitive ability, academic achievement, and behavioral data to answer a question about learning. School psychologists write them to inform special-education eligibility and instruction planning; private evaluators write them as independent educational evaluations. Most run 4 to 15 pages, and parents receive a copy of a school evaluation report at no cost.

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Psychological Evaluation Report

A psychological evaluation report is the written product of psychological testing: it integrates the referral question, history, behavioral observations, and standardized test results into an interpretation, a diagnosis, and recommendations. Psychologists write one after an assessment battery, addressed to the referrer and increasingly read by the patient. Most clinical reports run 3 to 12 pages.

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Psychological Testing Administration Note

A psychological testing administration note documents a test administration and scoring encounter: which standardized instruments were given, who administered each one (psychologist or technician), and the total face-to-face minutes supporting each billed unit of CPT 96136 to 96139. Psychologists, neuropsychologists, and testing technicians write one for every administration session. Most notes run 150 to 350 words plus the time log.

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Psychological Testing Scoring Note

A psychological testing scoring note records the professional evaluation side of psychological or neuropsychological testing: verifying and summarizing scores, integrating them with clinical data, and logging the dated minutes that support CPT 96130 to 96133. Psychologists and neuropsychologists write one per assessment episode, alongside the administration record and the evaluation report. Most run 200 to 400 words plus the score summary and time log.

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Test Write-Up Guides

Instrument-specific write-up guides with scored fictional samples: WISC-V, WAIS, BASC-3, Conners 4, MMPI-3, ADOS-2, and the other measures psychologists report on.

ABAS-3 Report Write-Up

The ABAS-3 (Adaptive Behavior Assessment System, Third Edition) is a norm-referenced measure of adaptive behavior, the everyday conceptual, social, and practical skills a person uses to function independently, rated entirely by forms: parent, teacher, and adult versions covering birth through age 89. Psychologists use it in intellectual-disability, autism, and disability evaluations. This page covers how to write up ABAS-3 results, with a fictional two-rater sample and a template.

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ADI-R Report Write-Up

The ADI-R (Autism Diagnostic Interview-Revised) is a standardized, semi-structured caregiver interview that gathers developmental history and current behavior when autism is part of the question. Psychologists and other trained clinicians use it as one input to an autism evaluation, and it yields a categorical classification, not a diagnosis. This page covers how to write up ADI-R results, with a fictional sample and a results-section template.

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ADOS-2 Report Write-Up

The ADOS-2 (Autism Diagnostic Observation Schedule, Second Edition) is a semi-structured observation used to assess social communication, play, and restricted or repetitive behaviors when autism is a question. Psychologists and other trained clinicians use it as one input to an autism evaluation, and it yields a classification, not a diagnosis. This page covers how to write up ADOS-2 results, with a fictional sample and a results-section template.

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BASC-3 Report Write-Up

The BASC-3 (Behavior Assessment System for Children, Third Edition) is a multi-informant rating system measuring behavioral, emotional, and adaptive functioning from age 2 through college age, with teacher, parent, and self-report forms. Psychologists and school psychologists use it in ADHD, emotional, and autism-related evaluations. This page covers how to write up BASC-3 results, with a fictional sample and a results-section template.

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Bayley-4 Report Write-Up

The Bayley-4 (Bayley Scales of Infant and Toddler Development, Fourth Edition) is an individually administered developmental assessment for children 16 days to 42 months old, published by Pearson in 2019. Psychologists, therapists, and early-intervention teams use it to measure cognitive, language, and motor development and to inform eligibility decisions. This page covers how to write up Bayley-4 results, with a fictional sample and a results-section template.

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BRIEF-2 Report Write-Up

The BRIEF-2 (Behavior Rating Inventory of Executive Function, Second Edition) is a rating scale of everyday executive function for ages 5 to 18, completed by parents, teachers, and adolescents themselves, scored as T scores across three indexes and a global composite. Psychologists use it in ADHD, autism, TBI, and special-education evaluations. This page covers how to write up BRIEF-2 results, with a fictional sample and a template.

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CAARS-2 Report Write-Up

The CAARS-2 (Conners Adult ADHD Rating Scales, 2nd Edition) is a 2023 self-report and observer rating scale measuring ADHD symptoms, impairment, and response style in adults 18 and older. Psychologists and psychiatrists use it to quantify symptom severity inside adult ADHD evaluations. This page covers how to write up CAARS-2 results, with a fictional sample, reviewer-flagged errors, and free templates.

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CARS-2 Report Write-Up

The CARS-2 (Childhood Autism Rating Scale, Second Edition) is a clinician-completed rating scale that quantifies autism symptom severity from direct observation, record review, and collateral information. Psychologists and other trained clinicians use it as one severity input within a broader autism evaluation, never as a standalone diagnosis. This page covers how to write up CARS-2 results, with a fictional sample and a results-section template.

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Conners 4 Report Write-Up

The Conners 4 (Conners 4th Edition) is a multi-informant rating scale measuring ADHD symptoms, co-occurring problems, and functional impairment for ages 6 to 18, with parent, teacher, and self-report forms. Psychologists, school psychologists, and pediatric clinicians use it in ADHD evaluations, school assessments, and treatment monitoring. This page covers how to write up Conners 4 results, with a fictional sample and a results-section template.

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D-KEFS Report Write-Up

The D-KEFS (Delis-Kaplan Executive Function System, 2001) is a battery of nine co-normed stand-alone tests of executive function for ages 8 to 89, with no overall composite by design. Neuropsychologists, clinical psychologists, and school psychologists select tests from it in ADHD, TBI, epilepsy, and dementia evaluations. This page covers how to write up D-KEFS results, with a fictional sample and free templates.

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KTEA-3 Report Write-Up

The KTEA-3 (Kaufman Test of Educational Achievement, Third Edition) is an individually administered academic achievement battery for ages 4:0 through 25:11, measuring reading, math, written language, and oral language with standard scores set to a mean of 100. Psychologists and school psychologists use it in specific learning disability evaluations for its norm-referenced error analysis and parallel forms. This page covers how to write up KTEA-3 results, with a fictional sample.

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MCMI-IV Report Write-Up

The MCMI-IV (Millon Clinical Multiaxial Inventory-IV, 2015) is a 195-item true/false personality inventory for adults 18 and older who are already in mental health assessment or treatment, published by NCS Pearson. Psychologists use it to clarify personality-pattern questions and plan treatment, reading results as prevalence-anchored Base Rate scores rather than T scores. This page covers how to write up MCMI-IV results, with a fictional sample and a results-section template.

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MIGDAS-2 Report Write-Up

The MIGDAS-2 (Monteiro Interview Guidelines for Diagnosing the Autism Spectrum, Second Edition) is a sensory-based diagnostic interview that yields a qualitative three-domain profile instead of scores. Psychologists and evaluation teams use it within autism evaluations, almost always paired with a scored instrument. This page covers how to write up MIGDAS-2 findings, with a fictional sample and a results-section template.

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MMPI-3 Report Write-Up

The MMPI-3 (Minnesota Multiphasic Personality Inventory-3, 2020) is a 335-item true/false broadband personality inventory for adults 18 and older, published by the University of Minnesota Press and distributed by Pearson. Psychologists use it in clinical, forensic, public-safety, and presurgical evaluations to assess emotional, thought, and behavioral dysfunction. This page covers how to write up MMPI-3 results, with a fictional sample and a results-section template.

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NEPSY-II Report Write-Up

The NEPSY-II (2007) is a developmental neuropsychological battery for ages 3 to 16 that yields subtest-level scores across six domains, with no overall composite by design. Psychologists and school psychologists use it to profile attention, language, memory, sensorimotor, social perception, and visuospatial skills in pediatric evaluations. This page covers how to write up NEPSY-II results, with a fictional sample and free templates.

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PAI Report Write-Up

The PAI (Personality Assessment Inventory, 1991) is a 344-item self-report inventory of adult personality and psychopathology for ages 18 to 89, authored by Leslie C. Morey and published by PAR. Psychologists use it in clinical, forensic, correctional, and post-offer public safety evaluations, valued for its treatment planning scales and fourth-grade reading level. This page covers how to write up PAI results, with a fictional sample and a results-section template.

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RBANS Report Write-Up

The RBANS (Repeatable Battery for the Assessment of Neuropsychological Status) is a roughly 30-minute neuropsychological screening battery: 12 subtests yield five index scores and a Total Scale score, with four parallel forms for retesting. Neuropsychologists, psychologists, and medical teams use it to screen and track cognition in dementia, stroke, and psychiatric care. This page covers how to write up RBANS results, with a fictional sample.

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SRS-2 Report Write-Up

The SRS-2 (Social Responsiveness Scale, Second Edition) is a 65-item rating scale quantifying autism-related social impairment from age 2 and a half through adulthood, completed by parents, teachers, and adults about themselves. Psychologists use it as a corroborating measure in autism evaluations and a progress measure in ABA programs. This page covers how to write up SRS-2 results, with a fictional sample and a results-section template.

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Vineland-3 Report Write-Up

The Vineland-3 (Vineland Adaptive Behavior Scales, Third Edition) is a norm-referenced measure of adaptive behavior: the communication, daily living, and social skills a person uses to function independently, from birth through adulthood, gathered by interview or by caregiver and teacher rating forms. Psychologists and developmental teams use it in autism, intellectual-disability, and disability evaluations. This page covers how to write up Vineland-3 results, with a fictional sample and a template.

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WAIS-5 / WAIS-IV Report Write-Up

The Wechsler Adult Intelligence Scale (WAIS) is the standard adult intelligence battery for ages 16 to 90: the WAIS-5 (2024) is the current edition, and the WAIS-IV (2008) remains in use during the transition. Psychologists and neuropsychologists use it in diagnostic, disability, accommodation, and forensic evaluations. This page covers how to write up WAIS results, with a fictional sample and the errors reviewers flag.

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WIAT-4 Report Write-Up

The WIAT-4 (Wechsler Individual Achievement Test, Fourth Edition) is an individually administered academic achievement battery for ages 4 through 50, measuring reading, mathematics, written expression, and oral language with standard scores set to a mean of 100. Psychologists, school psychologists, and specific-learning-disability evaluation teams use it to quantify academic skills against age or grade norms. This page covers how to write up WIAT-4 results, with a fictional sample and a results-section template.

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WISC-V Report Write-Up

The WISC-V (Wechsler Intelligence Scale for Children, Fifth Edition) is an individually administered intelligence test for ages 6 to 16, yielding a Full Scale IQ and five index scores covering verbal comprehension, visual spatial, fluid reasoning, working memory, and processing speed. Psychologists use it in special-education, learning-disability, and disability-benefit evaluations. This page covers how to write up WISC-V results, with a fictional sample and a results-section template.

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Woodcock-Johnson (WJ IV / WJ V) Report Write-Up

The Woodcock-Johnson is an individually administered, norm-referenced battery of cognitive and achievement tests built on Cattell-Horn-Carroll theory, currently sold in two editions: the WJ IV (2014) and the digital WJ V (2025). Psychologists, school psychologists, and educational diagnosticians use it in special-education, learning-disability, gifted, and accommodation evaluations. This page covers how to write up Woodcock-Johnson results, with a fictional sample and a results-section template.

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WPPSI-IV Report Write-Up

The WPPSI-IV (Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition) is an individually administered intelligence test for ages 2 years 6 months to 7 years 7 months, published in 2012. Psychologists use it for preschool special-education eligibility, kindergarten and gifted decisions, and the cognitive core of early-childhood evaluations. This page covers how to write up WPPSI-IV results, with a fictional sample and a results-section template.

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Care Coordination & Transitions

Referral letters, discharge and transfer summaries, and the notes that document coordinated care across providers and teams.

Australia Telehealth & MBS Case Conference Note

An MBS case conference note is the clinical record entry an Australian practitioner makes to substantiate a multidisciplinary or mental health case conference item under the Medicare Benefits Schedule. The regulations legislate recorded facts, not a form: the patient's agreement, the day with start and end times, participant names, and the matters discussed. Telehealth attendance notes add a documented eligibility pathway. Most run 150 to 400 words.

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Care Coordination Note

A care coordination note documents the work of organizing a client's care across providers: contacts made, referrals and their status, consent to share information, handoffs, and outcomes. Therapists, case managers, and integrated care teams write one whenever they arrange, share, or follow up on care with someone outside the session. Most run 75 to 250 words.

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Case Conference Note

A case conference note documents a pre-arranged meeting held by two or more providers to discuss and direct one identified client's care. It records the participants, times, decisions, and allocated tasks, plus whatever elements the payer requires when the conference is billed. Conferences are billable in Australia and Ontario and in limited US contexts. Most notes run 150 to 400 words.

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Case Management Note

A case management note documents one case management contact: work that helps a client gain access to medical, social, educational, and other services. Case managers, social workers, and community agency staff write one for every contact, including phone calls and collateral contacts, because the note is the evidence behind billed time. Most case management notes run 100 to 300 words.

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Chronic Care Management (CCM) Note

A chronic care management (CCM) note is the monthly documentation behind Medicare's CCM billing: a consent record, a comprehensive electronic care plan, and a time log showing at least 20 minutes of clinical staff care coordination for a patient with two or more chronic conditions. Care managers in primary care and integrated behavioral health teams keep it every enrolled month. Most months the record runs 150 to 400 words.

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Collaborative Care (BHI/CoCM) Note

A collaborative care note is the registry-backed record a behavioral health care manager keeps for each patient in the psychiatric Collaborative Care Model (CoCM) or general behavioral health integration (BHI). It logs contacts, validated symptom scores, psychiatric consultant recommendations, and clinical minutes across the calendar month. The billing practitioner's monthly claim under 99492, 99493, 99494, or 99484 stands on that time-and-registry trail.

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Consultation Response & Report

A consultation response, or consultation report, is the written reply a consultant sends to the provider who requested the consultation: findings, diagnostic impression, recommendations, and who does what next. It closes the referral loop the referral letter opened. Psychiatrists, psychologists, and therapists send one after an assessment or a completed course of treatment. Most run 150 to 700 words.

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Discharge Summary

A mental health discharge summary is the closing document of an episode of care: why treatment started, the course and response, final diagnoses, the client's condition and risk status at discharge, and the aftercare plan. Hospitals and community mental health centers must produce one under federal rules; in outpatient therapy it is professional convention, with some state exceptions. A typical summary runs 300 to 1,200 words.

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Hospital Consult & Liaison Note

A consultation-liaison (C-L) note records a psychiatric assessment of a hospital patient admitted under a non-psychiatric team, performed at that team's request. It answers the consult question, documents mental status, capacity, and risk, and returns numbered recommendations the requesting team can act on the same day. Most run 200 to 600 words.

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Medication Management Follow-Up Note

A medication management follow-up note is a prescriber's record of an established-patient psychiatric visit centered on medications: response, adherence, side effects, monitoring, and plan changes. Psychiatrists, psychiatric nurse practitioners, and physician assistants write one at every med check, billed in the US as an E/M visit (99212 to 99215). Most run 150 to 500 words.

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Multidisciplinary Team Meeting Note

A multidisciplinary team meeting note records an interdisciplinary discussion of one client's care: who attended, what each discipline reported, what the team decided and why, and the action items with owners and due dates. Treatment teams in inpatient, rehabilitation, hospice, and community behavioral health programs write one after each team meeting or staffing. Most run 100 to 400 words per client discussed.

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Psychiatric Consultation Note

A psychiatric consultation note records a psychiatrist's or psychiatric nurse practitioner's opinion on another provider's patient: the consult question, a focused history, mental status findings, an impression that answers the question, and numbered recommendations back to the referrer. Consultants write one after each referred evaluation in outpatient, primary care, and specialty settings. Most run 250 to 800 words.

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Referral Letter

A mental health referral letter is a signed, dated request from one clinician to another to assess or treat a named client. It states the referral question, relevant history, current medications, symptoms and measures, risk status, and what the referrer keeps doing while care continues. GPs, therapists, psychologists, and psychiatrists exchange them whenever care crosses providers. Most run 150 to 500 words.

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Return-to-Primary-Care Summary

A return-to-primary-care summary is the closing letter that transfers a stabilized behavioral health patient from specialty or integrated care back to their primary care clinician. It states diagnoses, treatment delivered, current outcome measures, medications and who prescribes them, a relapse prevention plan, and re-referral triggers. Psychologists, psychiatrists, and collaborative care teams send it at step-down; most run 300 to 600 words.

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Transfer-of-Care Summary

A transfer-of-care summary is the document a clinician writes when ongoing care moves to a new provider, giving the receiving clinician the client's current status, active risks, medications and supports, and pending items. Therapists, psychologists, counselors, and care coordinators write one whenever another clinician assumes the client. Most run 150 to 600 words, shorter than a discharge summary.

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Transitional Care Management (TCM) Note

A transitional care management (TCM) note is the medical-record documentation behind Medicare's 30-day post-discharge service, billed under CPT 99495 or 99496. It evidences the three billable components: interactive contact within two business days of discharge, a face-to-face visit within 14 days (99495) or 7 days (99496), and moderate or high complexity medical decision making. Practices keep one record per qualifying discharge; most run 250 to 600 words.

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Billing, Insurance & Practice Operations

Claim-support notes, prior authorizations, appeals, and the financial and operational documents that keep a practice running.

Advance Beneficiary Notice (ABN)

An Advance Beneficiary Notice (ABN), Form CMS-R-131, is the standardized written notice that tells an Original Medicare patient, before a specific service, that Medicare is expected to deny payment, so the patient can choose whether to proceed and accept the cost. Practice and billing staff issue it when a case-specific denial is expected, such as psychotherapy beyond covered frequency. The completed notice is one page.

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Appointment No-Show & Outreach Note

An appointment no-show note is a brief clinical-record entry documenting that a client missed a scheduled session or cancelled late, along with any outreach attempts and a risk-informed next step. Front desk staff record the missed appointment; the clinician documents outreach and any risk decision. Most run 75 to 200 words.

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Claim-Support Billing Note

A claim-support billing note is the documentation that ties a billed CPT or HCPCS code to what happened in session: the service, the time, the diagnosis it addressed, medical necessity, and an authenticated author. United States payers require these elements in the clinical record rather than a separate document. Clinicians use the template as a pre-claim check, a records-request response, or a compliant addendum. Most run 100 to 300 words.

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Communication Log & Portal Message Note

A communication log or portal message note documents a client contact that happens outside a scheduled session: a patient portal message, phone call, text, or secure email. Therapists, psychologists, and practice teams use it to record what was communicated, their clinical read of it, and the follow-up. Most entries run 50 to 200 words; a billed e-visit entry runs longer.

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Diagnosis & Problem List Update (ICD)

A diagnosis and problem list update is the dated, authored entry a clinician makes when adding, refining, correcting, or resolving a diagnosis in the medical record, including the ICD-10-CM code that flows onto claims. Clinicians, coders, and CDI teams use it whenever the active diagnosis list changes. Most entries run 50 to 200 words: a diagnostic statement plus the clinical support for it.

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Financial Policy & Fee Agreement

A financial policy and fee agreement is the signed contract between a therapy practice and a client that sets fees, billing and insurance terms, cancellation and no-show charges, and collection rules before treatment starts. Practices present it at intake alongside informed consent. No US statute requires one; ethics codes and payer contracts define what it must say. Most run one to three pages.

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Good Faith Estimate (No Surprises Act)

A good faith estimate (GFE) is the written notice of expected charges that the No Surprises Act requires US providers to give uninsured and self-pay clients, including therapy clients who pay out of pocket. It itemizes expected services, codes, and charges for up to 12 months of care. Required since January 1, 2022 under 45 CFR 149.610; most therapy GFEs run one to two pages.

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Incident & Adverse Event Report

An incident or adverse event report is an internal risk-management record of an unexpected event affecting a client, visitor, or staff member: a fall, medication error, elopement, assault, or suicide attempt. Staff file it with the practice or facility, separate from the clinical record. Facility and program rules often mandate it; for solo private practice it is convention. Most run 300 to 600 words.

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Insurance Appeal Letter

An insurance appeal letter is a written request asking a health plan to reverse an adverse benefit determination: a denied, reduced, or terminated mental health claim. Clinicians, billing staff, patients, or authorized representatives file it within the plan's appeal deadline, pairing the denial code with a clinical rebuttal. No law prescribes its format; most run 1 to 3 pages.

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Medical Necessity Letter

A medical necessity letter (also called a letter of medical necessity or LMN) is a clinician-authored narrative explaining why a specific service, level of care, or item is medically necessary for a particular patient. Therapists, psychologists, and psychiatrists send one to payers, FSA and HSA administrators, schools, and benefit programs to support coverage, reimbursement, or accommodations. Most run 1 to 3 pages.

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Patient Instructions & After-Visit Summary

An after-visit summary (AVS), also called a clinical summary or patient instructions, is a plain-language handout a client takes home after an appointment. It covers what happened in the visit, medications, the between-session plan, follow-up, and who to call. No US, Canadian, or Australian law requires one for outpatient therapy. Most run 150 to 400 words, about half a page.

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Peer-to-Peer Review Note

A peer-to-peer review note is the treating clinician's record of a call with a payer's medical or behavioral health reviewer about the medical necessity of requested services. Clinicians write it right after a payer P2P call, most often around a prior authorization or concurrent review denial. Most run 150 to 300 words and are filed in the general chart, not psychotherapy notes.

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Prior Authorization Request

A prior authorization request is the clinical justification packet a provider submits to a health plan to get a mental health service approved for coverage before it starts or continues. Practice staff or the clinician assemble it from the record: diagnosis, symptom severity, functional impairment, treatment history, risk, and a plan with measurable goals. No universal form exists; each payer or carve-out vendor sets its own.

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Prior Authorization Support Letter

A prior authorization support letter is a narrative letter a treating clinician sends to a health plan to justify why a mental health service should be authorized before it is delivered, or continued. It states the diagnosis, symptoms, functional impairment, treatment history, and the exact service requested, mapped to the plan's medical-necessity criteria. Many plans do not require it for routine outpatient therapy.

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Start-Stop Time Attestation

A start-stop time attestation is the notation in a psychotherapy progress note that records when the session began and ended, or the total face-to-face minutes, to support time-based codes such as 90832, 90834, and 90837. Clinicians add it to every timed session; payers and auditors use it to verify the billed code. Most versions run one to two lines inside the note.

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Utilization Review Summary

A utilization review summary is the clinical document a treating clinician or facility submits to a payer to justify continuing an authorized course of treatment or level of care. Payers call the process concurrent or continued-stay review. It compiles current symptoms, objective measures, risk status, treatment response, and the barriers to step-down. Most run 300 to 600 words or fill a payer portal form.

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Frequently asked questions

BastionGPT is trained, tuned, and clinically tested across 100+ behavioral health document types: SOAP, DAP, BIRP, PIE, and narrative progress notes, intake and diagnostic evaluations, biopsychosocial assessments, treatment plans, risk assessments and safety plans, psychological testing reports, discharge summaries, referral and medical-necessity letters, prior authorizations and appeals, and consent and privacy forms. A custom note option also accepts any free-form format you describe.

Yes. Copy and adapt any template or sample for your own practice, no signup required. The templates are educational resources; follow your organization, board, payer, and jurisdiction requirements.

No. Every sample in the library is fictional and written for education. No real patient information appears anywhere in these templates.

Yes. BastionGPT converts between formats, such as DAP to SOAP or a narrative note to a payer-facing progress note, without losing clinically important content. BastionGPT drafts, you review and sign.

Yes. The formats themselves are conventions used in all three countries, and key templates include a US, Canada, and Australia table covering naming and billing differences. BastionGPT supports HIPAA, PIPEDA, and Australian APP requirements.

Stop writing notes from scratch

BastionGPT drafts complete, compliant notes from bullets, dictation, or a session transcript. Many users report saving more than 90 minutes per day on documentation. HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.

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Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.