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Psychotherapy Visit Note
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Load follow-up visit forms
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Load initial visit forms
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Select visit type:
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Load patient consent form for collateral
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Patient Consent
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Information to be disclosed:
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Consent - Contact Name
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Consent - Relationship to Patient
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Consent - Contact Info
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Consent - Date Obtained
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Revoke consent
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Consent - Date Revoked
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Subjective
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Chief Complaint:
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History of present illness:
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Changes from last session:
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Medications:
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Is this appointment a follow-up for hospital/ER discharge?
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Load hospital discharge form
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Hospital / ER Discharge Follow-up
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Reviewed discharge summary:
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Patient understands discharge instructions:
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Patient adherent to discharge instructions:
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Barriers to adherence:
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Hospital/ER Discharge Date:
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Comments:
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Mental Health History
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Past psychiatric history:
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Past medication trials:
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Previous treatment:
• • •
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Comments:
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Medical History
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Significant medical problems and history:
• • •
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Comments:
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Review of Systems
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Check 'No' if all systems negative; if any systems positive, check 'Yes' and load RoS form):
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Load Review of Systems form
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Constitutional:
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Comments:
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Eyes:
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Comments:
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Ears/Nose/Mouth/Throat:
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Comments:
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Cardiovascular:
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Comments:
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Respiratory:
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Comments:
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Gastrointestinal:
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Comments:
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Genitourinary:
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Comments:
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Muscular:
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Comments:
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Integumentary:
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Comments:
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Neurological:
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Comments:
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Endocrine:
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Comments:
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Hematologic/Lymphatic:
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Comments:
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Allergies/Immune:
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Comments:
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Psychosocial History
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Family history:
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Birth and developmental history:
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Social history:
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Marital status:
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Children:
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Housing status:
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Comments:
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Education:
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Comments:
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Employment:
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Comments:
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Legal history:
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Substance use history:
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Trauma history:
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Safety concerns
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Cultural and religious background:
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Military history
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Firearms in the home
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Hobbies/Interests
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Support system
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