Counseling Note Template
Here is an intuitive counseling note template designed to elevate accuracy and improve clinical outcomes for all patients.
Fact Checked by RJ Gumban.
What is a Counseling Note Template?
As I’m sure you are aware, there is a range of different clinical documentation requirements for counselors – so many, that it can sometimes be hard to clearly differentiate between them. Counseling session notes, also referred to as therapy notes or psychotherapy notes, are private notes that a counselor writes about an encounter or session that they have had with a client. The word ‘private’ is very important in this context. As opposed to progress notes, which are shared between various third parties, counseling notes are meant only for the eyes of the practitioner who wrote them. Their primary purpose is to remind the counselor of different aspects of an encounter with a patient, and they include hypotheses, observations, questions, and general thoughts. Although are not technically legal documents, they still contain confidential patient information and must be stored accordingly. It is important that however you store your notes, they are protected against unauthorized access at all times and protect your patient’s privacy. To help counselors create effective and accurate notes, we’ve designed a note template. It can be downloaded and saved onto your device for easy future accessibility.
Printable Counseling Note Template
Check out these templates for these counseling notes to improve clinical documentation, productivity, and healthcare outcomes.
How to Use this Template for Counseling Note
We’ve tried to ensure that this counseling note template makes life easier for practitioners. In order to achieve this, we’ve made the process of accessing and utilizing the PDF resource extremely simple, you just have to follow these steps:
Step One: Download the PDF
The first thing you need to do is access and download the PDF template. We’ve included a link to the document on this page, and if you click on it you will be taken directly to a PDF version of the template. From here, you can save the document onto your computer, where it can be easily accessed at a later date.
Step Two: Complete the note after a session with a client
After you have had a counseling session with a client, it’s time to save your complete note. To ensure this process is seamless, it’s a good idea to have your template ready to be edited. You have a couple of options for how to do this: you can either edit the note directly online, or you can print the template and use a physical copy. While either of these options is perfectly fine, we recommend completing your counseling note online. Physical copies are easy to lose or damage, and they are hard to store in an organized way.
Step Three: Save the note securely
Finally, after the note is complete, you need to store it securely. Counseling notes contain PHI, which means they require certain safeguards in order to protect your patients’ privacy. It is also likely that you will want to revisit your counseling notes at a later date, so storing them somewhere accessible is optimal. One of the best solutions for storing clinical documentation is using an EHR, which has in-built safeguards and guarantees organization.
Counseling Note Example (Sample)
We think that sometimes the best way to learn how a resource like our template works is to see it in action. This is why we’ve created a sample counseling note, based on a fictitious session with a client. The specific details that are recorded in the note will vary depending on the sessions that you have with your clients, but this example should give you an insight into how the template works.
Download this Counseling Note Example here:
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Who Can Use this Printable Counseling Note Template?
There is a range of different specializations that counselors may be trained in, and we’ve ensured that our template is applicable to all of them:
- Grief Counseling
- Trauma Counseling
- Substance Use Counseling
- Family Counseling
- Relationship Counseling
- Group Counseling
- One-on-one Counseling
- Youth Counseling
Finding a resource that can be distributed between all counselors at your healthcare practice is important. One of the best aspects of utilizing these templates is the standardization that they introduce to businesses, which is why it’s helpful when they go be used across a variety of specializations. Our template is also applicable to counselors of varied experience. Whether you are a trainee counselor just beginning your career, or a seasoned professional, this note template will help you structure your documents and improve their accuracy.
Why is This Template Useful For Counselors?
It is common practice for counselors to be seeing more than one patient at a time. In addition to clinical work requirements, counselors also need to fulfill a range of different administrative tasks, including organizing their scheduling, following up with insurance claims, and of course, maintaining their documentation. Given how busy the schedule of a counselor gets, this template aims to ease the workload through its diverse uses:
- Saves time: One of the most valuable aspects of the note template is how much time it will save you. You no longer have to organize or structure your notes, as the formatting has already been done. Instead, you simply have to access the note and write down your thoughts, which will ultimately save you a lot of time.
- Organization: Staying organized during peak busy work hours can be hard, but it is made significantly easier with this note template. With easy access and an intuitive design, all of the organization has already been done for you.
- Standardization: Using the same template across all of your patients will introduce standardization into your practice. Essentially, this will make it much easier for you to review your notes at a later date and extract relevant information.
Why Use Carepatron For Counseling Notes?
Utilizing practice management software when it comes to writing documentation, including counseling notes, is one of the best decisions you can make for your healthcare practice. Carepatron’s system is integrated with robust and sophisticated tools that are designed to improve the processes at healthcare practices. With voice-to-text transcription software and extensive template options, using Carepatron is guaranteed to optimize the documentation at your counseling practice. Furthermore, Carepatron manages storage for you. An entirely online platform, Carepatron has robust storage capabilities that can securely house your documents. Employing bank-grade encryption, as well as a range of other safeguards, ensures that your patient's privacy is protected at all times. We understand that introducing new and unfamiliar systems into your counseling practice can be daunting, but Carepatron is truly the way to go if you want to optimize both administrative and clinical processes.
Commonly asked questions
Unlike progress notes, there is so no specific recommended way to format a counseling note. How you choose to structure the information is entirely up to you, and the type of data you are recording. Because of this, we have designed the template with a fairly free structure, allowing you to take control over how you want to present your notes.
The specific information that you include in your counseling notes is largely dependent on the type of session that you have with a client. The purpose of these types of documents is to record information that may be valuable at a later date that doesn’t typically go in progress notes. This could include general thoughts, ideas, hypotheses, or observations.
Because the aim of counseling notes is to remind you of important details regarding a session with a patient, you need to ensure they are accurate. As such, the best time to write your counseling notes is immediately after you have an encounter with a patient. This ensures the information is accurate and detailed enough to be of value in the future.
