185 Templates for 70+ Professions
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Profession-specific, AI-powered templates ready to generate polished clinical notes from your recordings. SOAP, MBS Medicare, NDIS, therapy modalities, and more.
Showing 185 of 185 templates
- Clinical
SOAP Note
The most widely used clinical note format across medicine and allied health. Captures the client's self-report (S), your observations and findings (O), your clinical impression (A), and the next steps (P). Suits problem-focused encounters, follow-ups, and any setting where standardised, transferable documentation matters.
Structure · 4 sections- Subjective
- Objective
- Assessment
- Plan
Built for- General Practitioner
- Physiotherapist
- Nurse Practitioner
- Dietitian
- +24 more
- Clinical
DAP Note
Streamlined three-part format favoured in mental health, counselling, and psychotherapy. The Data section combines what the client reported with what you observed; Assessment captures clinical impressions and progress against goals; Plan sets next steps and homework. Faster than SOAP without losing clinical reasoning.
Structure · 3 sections- Data
- Assessment
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +23 more
- Clinical
Structured Session Note (BIRP/GIRP/PIRP)
Unified structured session note covering BIRP (Behaviour), GIRP (Goals), and PIRP (Problem) formats. The AI selects the appropriate framing based on your documentation preference.
Structure · 4 sections- Behaviour / Goals / Problem
- Intervention
- Response
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +25 more
- Clinical
Process Note
Detailed narrative account of the therapeutic process, including therapist reflections and clinical observations.
Structure · 5 sections- Presenting Issues
- Session Content
- Therapist Observations
- Reflections
- Plan
Built for- Psychologist
- Clinical Psychologist
- Psychotherapist
- Counsellor
- +14 more
- Clinical
Session Note
General-purpose session documentation suitable for a wide range of clinical and allied health encounters, including therapy sessions and treatment sessions.
Structure · 7 sections- Homework Review
- Session Summary
- Key Themes
- Interventions
- Client Response
- Progress Toward Goals
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +32 more
- Clinical
Initial Assessment
Comprehensive intake assessment covering presenting concerns, history, risk, and treatment goals.
Structure · 6 sections- Presenting Concerns
- History
- Mental State Examination
- Risk Assessment
- Formulation
- Treatment Goals
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Counsellor
- +29 more
- Clinical
Case Note
Brief, narrative-style note for routine case management, contact records, and inter-agency coordination. Lighter than a full session note — captures who you spoke with, what was discussed, and any actions or follow-up. Useful for community services, social work, and case-managed care.
Structure · 5 sections- Contact Details
- Purpose
- Discussion
- Actions
- Follow-Up
Built for- Social Worker
- Case Manager
- Youth Worker
- Community Services Worker
- +16 more
- Clinical
Consultation Note
Documentation for specialist consultations, second opinions, and inter-professional referrals.
Structure · 5 sections- Reason for Referral
- History
- Examination
- Impression
- Recommendations
Built for- Psychiatrist
- Paediatrician
- General Practitioner
- Neuropsychologist
- +14 more
- Clinical
Psychiatric Admission Note
Comprehensive admission note for inpatient psychiatry, mental health units, and acute crisis services. Covers presenting illness, psychiatric and medical history, MSE, risk assessment, formulation, provisional diagnosis, and an initial management plan. Built for the structure ward teams and registrars expect on first contact.
Structure · 7 sections- Presenting Problem
- Psychiatric History
- Medical History
- Mental State Examination
- Risk Assessment
- Formulation
- Management Plan
Built for- Psychiatrist
- Mental Health Nurse
- Psychologist
- Clinical Psychologist
- +4 more
- Clinical
Telehealth Consultation
Documentation format adapted for telehealth and phone consultations. Captures the technology used, identity verification, environment safety, consent for remote care, and any limitations of the modality — alongside standard clinical content. Aligned with AHPRA and Medicare telehealth requirements.
Structure · 5 sections- Mode of Delivery
- Presenting Issues
- Assessment
- Plan
- Telehealth Suitability
Built for- General Practitioner
- Psychologist
- Clinical Psychologist
- Psychiatrist
- +21 more
- Clinical
Welfare Concern Record
Documentation for welfare concerns, safeguarding observations, and duty of care reporting.
Structure · 5 sections- Concern Details
- Observations
- Actions Taken
- Notifications
- Follow-Up
Built for- School Counsellor
- Social Worker
- Youth Worker
- Teacher
- +11 more
- Clinical
Psychosocial Assessment
Comprehensive assessment of psychosocial factors including living situation, supports, and barriers.
Structure · 7 sections- Demographics
- Presenting Issues
- Social History
- Support Network
- Risk Factors
- Strengths
- Recommendations
Built for- Social Worker
- Counsellor
- Community Services Worker
- Psychologist
- +10 more
- Clinical
Group Session Note
Documentation for group therapy and group program sessions with participant-level observations.
Structure · 6 sections- Group Details
- Session Topic
- Activities
- Participant Observations
- Facilitator Notes
- Next Session
Built for- Psychologist
- Clinical Psychologist
- Social Worker
- Occupational Therapist
- +14 more
- Clinical
Crisis Intervention Record
Detailed record of an acute crisis contact — what triggered the presentation, the de-escalation approach used, risk assessed at the time, and the safety plan put in place. Captures the critical decisions and rationale required for medico-legal review and continuity of care after the event.
Structure · 6 sections- Crisis Trigger
- Presentation
- De-escalation Strategies
- Risk Assessment
- Outcome
- Referrals/Follow-up
Built for- Social Worker
- Psychologist
- Clinical Psychologist
- Mental Health Nurse
- +12 more
- Clinical
Comp. Suicide Risk Assessment
Detailed suicide risk formulation covering ideation, intent, plan, and protective factors.
Structure · 7 sections- Current Ideation
- Intent & Plan
- History of Attempts
- Risk Factors
- Protective Factors
- Risk Level
- Safety Plan
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Mental Health Nurse
- +12 more
- Clinical
Palliative Care Consultation
Holistic care note for palliative patients addressing physical, emotional, and spiritual needs.
Structure · 6 sections- Symptom Management
- Functional Status
- Psychosocial Support
- Family Needs
- Advance Care Planning
- Plan
Built for- Nurse Practitioner
- General Practitioner
- Social Worker
- Counsellor
- +10 more
- Clinical
AOD Comprehensive Assessment
Alcohol and Other Drugs assessment covering substance use history, dependence, and impacts.
Structure · 6 sections- Substance Use History
- Severity of Dependence
- Physical Health
- Psychosocial Impact
- Readiness for Change
- Treatment Goals
Built for- Social Worker
- Counsellor
- Psychologist
- Clinical Psychologist
- +9 more
- Clinical
Pain Management Assessment
Biopsychosocial pain assessment covering pain history, character and intensity, functional interference, mood and sleep impact, treatment history, and coping strategies. Suitable for chronic pain, persistent musculoskeletal conditions, and pain-management referrals — informs an integrated treatment plan.
Structure · 6 sections- Pain History
- Intensity & Quality
- Aggravating/Relieving
- Functional Interference
- Psychological Impact
- Management Plan
Built for- Physiotherapist
- Psychologist
- Clinical Psychologist
- Nurse Practitioner
- +9 more
- Clinical
Neuroaffirming Session Note
Session documentation for neurodiversity-affirming therapy, capturing sensory state, energy levels, masking load, and progress framed as self-understanding and environmental fit.
Structure · 6 sections- Check-In & Energy Level
- Session Focus
- Strengths Observed
- Strategies Explored
- Accommodations
- Plan
Built for- Psychologist
- Clinical Psychologist
- Occupational Therapist
- Speech Pathologist
- +14 more
- Clinical
Child Therapy Session Note (Brief)
Brief session note for child therapy including play-based and developmental observations, suitable for shorter sessions.
Structure · 5 sections- Session Details
- Presentation
- Session Content
- Parent/Carer Feedback
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +13 more
- Clinical
Child Therapy Session Note (Comprehensive)
Comprehensive child therapy note with detailed developmental, behavioural, and family observations for complex cases.
Structure · 8 sections- Session Details
- Current Presentation
- Developmental Observations
- Session Content
- Family/System Factors
- Risk Assessment
- Treatment Progress
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +14 more
- Clinical
Psychiatric Medication Review
Structured note for psychiatric medication reviews covering current medications, side effects, efficacy, and changes.
Structure · 7 sections- Session Details
- Current Medications
- Medication Efficacy
- Side Effects
- Mental State Examination
- Risk
- Plan
Built for- Psychiatrist
- General Practitioner
- Nurse Practitioner
- Mental Health Nurse
- +5 more
- Clinical
Mental Status Examination (MSE)
Standalone Mental Status Examination covering appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition, and insight/judgement. Use as a dedicated MSE record (e.g. on admission) or as an evidence anchor inside a broader assessment. Written in formal psychiatric register.
Structure · 11 sections- Examination Details
- Appearance
- Behaviour
- Speech
- Mood and Affect
- Thought
- Perception
- Cognition
- Insight and Judgement
- Risk
- Summary
Built for- Psychiatrist
- Psychologist
- Clinical Psychologist
- Mental Health Nurse
- +10 more
- Clinical
PROC Note
Five-part psychotherapy progress note format that is structured around an explicit, stated session objective and goal-attainment review. Captures the client's Presentation, a Review of the inter-session period, the agreed session Objective, the therapeutic Content (including formulation, intervention response, and risk), and the forward Plan. Particularly suited to ongoing psychological therapy, supervision-rich practice, and registrar/trainee settings where session-by-session reasoning needs to be visible in the record.
Structure · 5 sections- Presentation
- Review
- Objective
- Content
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +13 more
- MBS Medicare MBS Item 965
GP Chronic Condition Management Plan (965)
GP Chronic Condition Management Plan (MBS item 965) for patients with chronic and complex conditions. Documents the diagnoses, agreed goals, patient and GP actions, services from other providers, and a mandatory review date. Structured to satisfy the post-1-Jul-2025 GPCCMP framework that replaced the legacy GPMP (721) and TCA (723) items, and to support the patient's ongoing chronic care.
Structure · 9 sections- Chronic Conditions
- Current Health Status
- Current Medications
- Treatment Goals
- Actions and Responsibilities
- Allied Health Involvement
- Education and Resources Provided
- Review Date
- Patient Agreement
Built for- General Practitioner
- MBS Medicare MBS Item 705
Health Assessment 75+ (705)
Annual Health Assessment for patients aged 75 and over (MBS item 705 — the 45-to-<60-minute duration tier of the GP long health assessment series, applicable to seven eligible cohorts including 75+). Comprehensive review across medical, psychological, and social domains — including cognition, falls risk, continence, nutrition, social supports, and advance care planning. Builds the evidence base required for the item claim and identifies issues warranting a GPCCMP (item 965).
Structure · 9 sections- Health and Physical Function
- Psychological Function
- Social Function
- Physical Examination
- Falls Risk Assessment
- Activities of Daily Living
- Medication Review
- Advance Care Planning
- Summary and Actions
Built for- General Practitioner
- MBS Medicare MBS Items 80000–80015
Better Access Individual Session (80000-80165)
Unified Better Access individual session template covering Clinical Psychologists, Registered Psychologists, MH Social Workers, and MH OTs. Select the appropriate MBS item based on your profession, duration, and location.
Structure · 15 sections- Client Details
- Session Details
- MBS Item Number
- Referral Details
- Presenting Concerns
- Psychosocial Context
- Mental State Observations
- Therapeutic Interventions / FPS
- Client Response
- Progress Toward Treatment Goals
- Risk Assessment
- Homework/Between-Session Tasks
- Plan
- Medicare Compliance
- Clinician Details
Built for- Clinical Psychologist
- Psychologist
- Social Worker
- Occupational Therapist
- +2 more
- MBS Medicare MBS Items 80020–80025
Better Access Group Session (80020-80170)
Unified Better Access group session template covering Clinical Psychologists, Registered Psychologists, and MH Social Workers. 6-10 patients, minimum 60 minutes.
Structure · 10 sections- Group Details
- MBS Item Number
- Participants
- Session Content
- Group Dynamics
- Individual Observations
- Homework Assigned
- Risk Concerns
- Next Session
- Clinician Details
Built for- Clinical Psychologist
- Psychologist
- Social Worker
- Occupational Therapist
- +2 more
- MBS Medicare MBS Items 81000–93029
NDPSC — Non-directive Pregnancy Support Counselling (81010 / 93026 / 93029)
Non-directive Pregnancy Support Counselling — the only MBS pathway available to credentialled mental health nurses (item 81010 in person; 93026 video; 93029 phone). Documents pregnancy status, referral, the non-directive framing of the session, service count against the 3-per-pregnancy cap, risk screen, and onward supports. Aligned with MBS Online descriptors and Services Australia eligibility requirements.
Structure · 13 sections- Client Details
- Session Details
- MBS Item Number
- Pregnancy Status
- Referral
- Service Count
- Reason for Counselling
- Session Content (non-directive)
- Risk Screen
- Onward Supports
- Plan
- Communication
- Clinician Details
Built for- Mental Health Nurse
- Registered Nurse
- Social Worker
- Psychologist
- MBS Medicare MBS Item 10960
CDM Physiotherapy (10960)
Chronic Disease Management physiotherapy session (MBS item 10960). Documents the chronic condition being managed, treatment goals from the referring GPCCMP (item 965, post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), intervention provided, response, and recommendations back to the GP. Structured to evidence the eligibility and content the item requires.
Structure · 12 sections- Client Details
- Session Details
- GP Referral Details
- Subjective
- Objective
- Assessment
- Treatment Provided
- Progress Toward CDM Goals
- Home Exercise Program
- Plan
- GP Communication
- Clinician Details
Built for- Physiotherapist
- MBS Medicare MBS Item 10958
CDM Occupational Therapy (10958)
Chronic Disease Management occupational therapy session (MBS item 10958). Documents the chronic condition, functional goals from the referring chronic condition management plan (GPCCMP item 965 post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), intervention provided (e.g. activity modification, equipment, energy conservation), and recommendations back to the GP. Structured for the Medicare claim and continuity of care.
Structure · 12 sections- Client Details
- Session Details
- GP Referral Details
- Occupational Profile
- Functional Assessment
- Intervention
- Progress Toward Care Plan Goals
- Recommendations
- Home Program
- Plan
- GP Communication
- Clinician Details
Built for- Occupational Therapist
- MBS Medicare MBS Item 965
CDM Speech Pathology (10970)
Chronic Disease Management speech pathology session (MBS item 10970). Documents the chronic condition (e.g. dysphagia, post-stroke communication), goals from the referring chronic condition management plan (GPCCMP item 965 post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), intervention delivered, and feedback to the GP. Structured to satisfy the Medicare item content requirements.
Structure · 12 sections- Client Details
- Session Details
- GP Referral Details
- Presenting Concerns
- Assessment Findings
- Intervention
- Current Recommendations
- Progress Toward Care Plan Goals
- Home Program
- Plan
- GP Communication
- Clinician Details
Built for- Speech Pathologist
- MBS Medicare MBS Item 10954
CDM Dietetics (10954)
Chronic Disease Management dietetic session (MBS item 10954). Documents the chronic condition (e.g. diabetes, CKD, weight-related comorbidities), nutrition goals from the referring chronic condition management plan (GPCCMP item 965 post-1-Jul-2025; legacy GPMP plans continue under transition arrangements until 1 July 2027), dietary assessment and intervention, and feedback to the GP. Structured to satisfy the Medicare item requirements.
Structure · 12 sections- Client Details
- Session Details
- GP Referral Details
- Anthropometry
- Relevant Pathology
- Dietary Assessment
- Nutrition Intervention
- Progress Toward Care Plan Goals
- Dietary Recommendations
- Plan
- GP Communication
- Clinician Details
Built for- Dietitian
- MBS Medicare MBS Item 23
GP MHTP Review (Items 23 / 36 / 44 — AN.0.56 timing)
GP Mental Health Treatment Plan review under the time-tiered attendance items (23 Level B, 36 Level C, 44 Level D). The legacy dedicated review item 2712 was retired; the AN.0.56 timing rule still applies — at least 4 weeks since the MHTP was prepared and at least 3 months since the previous review.
Structure · 14 sections- Patient Details
- Review Details
- Billing Eligibility Check
- Allied Health Provider Feedback
- Patient Self-Report
- Mental State Examination
- Psychometric Reassessment
- Progress Toward Treatment Goals
- Review Decision
- Updated Risk Management
- Updated Treatment Plan
- Next MHTP Review
- Patient Agreement
- GP Details
Built for- General Practitioner
- MBS Medicare MBS Item 291
Psychiatry Initial Consultation (291/296)
Initial psychiatric assessment for new outpatients. Use MBS item 296 for a comprehensive new-patient consultation or 291 for a GP-managed patient assessment with management plan back to the GP. Covers presentation, history, MSE, risk, formulation, provisional diagnosis, and initial management.
Structure · 19 sections- Patient Details
- Consultation Details
- MBS Item
- Referral Details
- History of Presenting Complaint
- Psychiatric History
- Medical History
- Substance Use
- Family History
- Personal History
- Mental State Examination
- Risk Assessment
- Formulation
- Diagnosis
- Management Plan
- Recommendations to GP
- Follow-Up
- Communication
- Psychiatrist Details
Built for- Psychiatrist
- MBS Medicare MBS Items 300–308
Psychiatry Ongoing Consultation (300-308)
Ongoing psychiatric review consultation, billed by duration across MBS items 300–308. Captures interval history, MSE, response to medication and/or psychotherapy, risk re-assessment, and updated management. Suitable for routine reviews, medication titration, and shared-care updates back to the GP.
Structure · 11 sections- Patient Details
- Consultation Details
- MBS Item
- Interval History
- Medication Review
- Mental State
- Risk Assessment
- Progress
- Plan
- GP Communication
- Psychiatrist
Built for- Psychiatrist
- MBS Medicare MBS Item 91177
Family/Carer Support Session — Video (91177)
Better Access video session with family member or carer to support patient treatment, claimed by registered psychologists under MBS 91177. ≥50 min. Max 2 per calendar year. Counts toward the patient’s annual Better Access allocation. (Other Better Access providers — clinical psychologists, social workers, OTs — bill different family/carer items, not this template.)
Structure · 12 sections- Patient Details
- Family Member/Carer Details
- Session Details
- Referral
- Purpose of Session
- Issues Discussed
- Interventions
- Carer Wellbeing
- Outcomes
- Confidentiality
- Plan
- Clinician Details
Built for- Psychologist
- NDIS
Functional Capacity Assessment
Functional Capacity Assessment evidencing the impact of disability on daily life — across self-care, mobility, communication, learning, social interaction, and self-management. Written in the structure NDIA reviewers expect, with explicit links between impairment, functional impact, and reasonable-and-necessary supports for access requests and plan reviews.
Structure · 6 sections- Participant Details
- Assessment Methods
- Functional Domains
- Support Needs
- Recommendations
- NDIS Goals
Built for- Occupational Therapist
- Physiotherapist
- Psychologist
- Clinical Psychologist
- +4 more
- NDIS
Access Request Report
Supporting evidence report for NDIS access requests, documenting disability and functional impact.
Structure · 6 sections- Participant Details
- Diagnosis
- Functional Impact
- Permanence
- Support Requirements
- Recommendations
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- General Practitioner
- +5 more
- NDIS
NDIS Progress Report
Progress report for NDIS plan reviews documenting goal achievement and ongoing support needs.
Structure · 6 sections- Participant Details
- Plan Goals
- Progress Summary
- Outcome Measures
- Ongoing Needs
- Recommendations
Built for- Occupational Therapist
- Physiotherapist
- Speech Pathologist
- Psychologist
- +12 more
- NDIS
NDIS Support Report
Support report recommending NDIS-funded supports with the clinical rationale and evidence behind each. Covers participant goals, functional impact, supports trialled, the proposed plan (including frequency and duration), and how each support meets the reasonable-and-necessary criteria. Designed for plan reviews and reasonable-and-necessary justifications.
Structure · 6 sections- Participant Details
- Current Supports
- Identified Gaps
- Recommended Supports
- Frequency
- Rationale
Built for- Occupational Therapist
- Speech Pathologist
- Psychologist
- Clinical Psychologist
- +5 more
- NDIS
Mealtime Management Report
Mealtime management assessment and recommendations for NDIS participants with swallowing or feeding needs.
Structure · 6 sections- Participant Details
- Mealtime Assessment
- Swallowing Status
- Texture Recommendations
- Mealtime Plan
- Risk Management
Built for- Speech Pathologist
- Occupational Therapist
- Dietitian
- NDIS
Equipment Prescription
Equipment prescription report for assistive technology funding under the NDIS. Documents the participant's functional needs, options considered (including trial outcomes), the recommended item with specifications and supplier quote, and how it addresses identified goals. Structured to satisfy AT assessor template expectations.
Structure · 6 sections- Participant Details
- Functional Needs
- Equipment Recommended
- Justification
- Quotes
- Trial Outcomes
Built for- Occupational Therapist
- Physiotherapist
- Speech Pathologist
- Rehabilitation Counsellor
- NDIS
Assistive Technology Report
Comprehensive assistive technology assessment and recommendation report for NDIS participants.
Structure · 6 sections- Participant Details
- AT Assessment
- Current Technology
- Recommended AT
- Training Needs
- Implementation Plan
Built for- Occupational Therapist
- Speech Pathologist
- Physiotherapist
- Audiologist
- +1 more
- NDIS
NDIS Session Note
Session documentation linking therapy activities to NDIS plan goals and line items. Required for NDIS Commission audits.
Structure · 6 sections- Participant Details
- NDIS Goals Addressed
- Session Activities
- Participant Response
- Progress Toward Goals
- Plan
Built for- Occupational Therapist
- Physiotherapist
- Speech Pathologist
- Psychologist
- +14 more
- NDIS
Behaviour Support Plan (BSP)
Legally required behaviour support plan under NDIS for participants with behaviours of concern, including restrictive practice documentation and fade-out plans.
Structure · 7 sections- Participant Profile
- Behaviour Assessment
- Functional Analysis
- Positive Strategies
- Restrictive Practices
- Implementation Plan
- Monitoring & Review
Built for- Psychologist
- Clinical Psychologist
- Social Worker
- Occupational Therapist
- +6 more
- NDIS
Plan Review Evidence Summary
Concise evidence summary for NDIS plan review meetings, aggregating goal achievement, funding utilisation, and recommendations for the next plan.
Structure · 6 sections- Participant Details
- Plan Period Summary
- Goal Achievement
- Funding Utilisation
- Ongoing Support Needs
- Recommendations for Next Plan
Built for- Occupational Therapist
- Physiotherapist
- Speech Pathologist
- Psychologist
- +11 more
- NDIS
SIL Shift Note
Shift documentation for Supported Independent Living covering daily routines, health monitoring, behavioural observations, and handover.
Structure · 6 sections- Participant Details
- Shift Details
- Daily Activities
- Health & Wellbeing
- Incidents
- Handover Notes
Built for- Community Services Worker
- Case Manager
- Social Worker
- Mental Health Nurse
- +5 more
- NDIS
NDIS Incident Report
NDIS Commission-compliant incident report with reportable incident classification, required timeframes, and follow-up actions.
Structure · 6 sections- Participant Details
- Incident Details
- Response Actions
- Reportable Incident Assessment
- Root Cause Analysis
- Follow-Up Plan
Built for- Case Manager
- Support Coordinator
- Community Services Worker
- Social Worker
- +8 more
- NDIS
Home Modification Report
Occupational Therapy report for NDIS Capital - Home Modifications funding covering structural modifications, functional assessment, and costings.
Structure · 6 sections- Participant Details
- Home Assessment
- Functional Limitations
- Proposed Modifications
- Quotes & Costings
- Risk Assessment
Built for- Occupational Therapist
- Physiotherapist
- NDIS
Transition Planning Report
NDIS transition planning for key life stages (school leaver, moving to SIL, ageing) covering gap analysis, stakeholder input, and milestone timelines.
Structure · 7 sections- Participant Details
- Current Situation
- Transition Goals
- Support Requirements
- Stakeholder Input
- Transition Timeline
- Risk Assessment
Built for- Occupational Therapist
- Psychologist
- Clinical Psychologist
- Social Worker
- +9 more
- NDIS
Communication Assessment & AAC Recommendation
Speech Pathology assessment of communication needs with multimodal AAC feature matching, trial outcomes, and implementation plan.
Structure · 7 sections- Participant Details
- Communication Profile
- Assessment Methods
- Current Communication
- AAC Trial Results
- Recommended System
- Implementation Plan
Built for- Speech Pathologist
- Occupational Therapist
- Audiologist
- NDIS
NDIS Service Agreement
Service agreement template for NDIS participants outlining supports, costs, scheduling, and cancellation terms.
Structure · 8 sections- Provider Details
- Participant Details
- Support Items
- Service Schedule
- Pricing
- Cancellation Policy
- Review & Variation
- Signatures
Built for- Support Coordinator
- Case Manager
- Occupational Therapist
- Physiotherapist
- +7 more
- NDIS
NDIS Incident Report (Quick)
Reportable incident template for NDIS registered providers. Must be submitted within 24 hours for serious incidents.
Structure · 6 sections- Incident Details
- Incident Type
- Description
- Immediate Actions
- Follow-Up
- Notifications
Built for- Support Coordinator
- Case Manager
- Occupational Therapist
- Physiotherapist
- +5 more
- NDIS
NDIS Plan Review Summary (NDIA Submission)
Comprehensive plan review summary for submission to NDIA, covering goal progress, outcomes, and recommendations for the next plan period.
Structure · 6 sections- Participant Details
- Current Plan Period
- Goal Progress
- Assessment Outcomes
- Functional Changes
- Recommendations
Built for- Support Coordinator
- Case Manager
- Occupational Therapist
- Physiotherapist
- +7 more
- NDIS
SC Contact Note
Concise contact note for any single interaction (phone, email, SMS, text, or brief in-person) between a Support Coordinator and a participant, family member, or provider. Captures the action taken, decisions made, and follow-up — the workhorse note that evidences day-to-day coordination.
Structure · 6 sections- Contact Details
- Purpose
- Summary
- Actions Agreed
- Follow-Up
- Billable
Built for- Support Coordinator
- Case Manager
- Social Worker
- Disability Support Worker
- +1 more
- NDIS
SC Home Visit Note
Extended in-person visit documentation for a Support Coordinator visiting a participant at home or in their community setting. Captures the setting, who was present, wellbeing and safeguarding observations, discussion, agreements reached, and follow-up actions — the longest single note an SC writes and the highest-value template for time saved.
Structure · 9 sections- Visit Details
- Setting & Present
- Purpose
- Wellbeing Observations
- Safeguarding Observations
- Discussion
- Agreements
- Action Items
- Next Contact
Built for- Support Coordinator
- Case Manager
- Social Worker
- Disability Support Worker
- +1 more
- NDIS
SC Implementation Plan
Written once at the start of each NDIS plan cycle, this template translates an approved NDIS plan into an operational implementation plan: which goals will be pursued first, which providers and services will be engaged, what budgets are allocated where, and what risks need monitoring. Evidence of coordination activity for plan reviews.
Structure · 8 sections- Plan Details
- Plan Goals
- Services to Engage
- Providers Identified
- Budget Allocation
- Timeline
- Risks & Mitigations
- Review Schedule
Built for- Support Coordinator
- Case Manager
- NDIS
SC Provider Engagement Note
Discrete record of provider research, quote comparison, fit assessment, and engagement decisions for a single service. Protects the Support Coordinator if NDIA later queries why a particular provider was chosen and demonstrates value-for-money decision-making.
Structure · 7 sections- Service Required
- Providers Considered
- Quotes Obtained
- Fit Assessment
- Capacity Check
- Decision & Rationale
- Booking Outcome
Built for- Support Coordinator
- Case Manager
- NDIS
SC Monthly Progress Update
Monthly summary for the participant and their family — and sometimes for the NDIA — of what was coordinated in the month, services engaged, indicative budget used vs allocated, outcomes against plan goals, and upcoming priorities. Builds the audit-defensible case for plan review.
Structure · 7 sections- Period
- Work Completed
- Services Engaged
- Budget Snapshot
- Goal Outcomes
- Upcoming Priorities
- Participant Voice
Built for- Support Coordinator
- Case Manager
- NDIS
SC Initial Intake Note
The first substantive note after a Support Coordination engagement is established — typically after a participant's plan is approved and the SC has had their first meeting. Captures the participant's understanding of their plan, current supports, immediate priorities, risks, and the SC's onboarding action items.
Structure · 7 sections- Engagement Details
- Plan Snapshot
- Goal Understanding
- Current Supports
- Immediate Priorities
- Risk Factors
- Onboarding Actions
Built for- Support Coordinator
- Case Manager
- NDIS
SC Plan Review Report
Formal report supporting an NDIS plan reassessment, written from the Support Coordinator's coordinating perspective rather than a clinical lens. Summarises the plan period, goal-by-goal progress, outcomes, unmet needs, and evidence-based recommendations for the next plan.
Structure · 7 sections- Report Details
- Plan Period Summary
- Goal-by-Goal Progress
- Outcomes Achieved
- Unmet Needs
- Evidence for Next Plan
- Recommendations
Built for- Support Coordinator
- Case Manager
- NDIS
SC Care Team Meeting Note
Multi-disciplinary care team meeting documentation for participants with multiple providers. Captures attendees, agenda, decisions made, action distribution, and information sharing — common in NDIS coordination but often poorly documented.
Structure · 8 sections- Meeting Details
- Attendees
- Agenda
- Discussion
- Decisions
- Action Distribution
- Information Shared
- Next Meeting
Built for- Support Coordinator
- Case Manager
- Social Worker
- Occupational Therapist
- +1 more
- NDIS
SC Handover / Transfer Note
Comprehensive handover document written when a Support Coordinator transfers a participant to another SC — within or between organisations. Aggregates plan status, active services, outstanding actions, key contacts, risks, and handover items. SC turnover is high; this protects continuity.
Structure · 8 sections- Handover Details
- Participant Summary
- Plan Status
- Active Services
- Outstanding Actions
- Key Contacts
- Risks & Sensitivities
- Handover Items
Built for- Support Coordinator
- Case Manager
- NDIS
SC Closure / Discharge Note
End-of-engagement record for when Support Coordination ceases — typically because the participant no longer has SC funding, has moved providers, or has self-discharged. Captures engagement period, outcomes, outstanding work, reasons for closure, onward referrals, and final balance.
Structure · 7 sections- Closure Details
- Engagement Period Summary
- Goals Achieved
- Outstanding Work
- Reasons for Closure
- Onward Referrals
- Final Communication
Built for- Support Coordinator
- Case Manager
- NDIS
SC Family Contact Note
Documentation for contacts where the SC interacts with a family member, carer, or informal supporter ON BEHALF of the participant — particularly when the participant is absent. Family-only contacts are legally sensitive: consent and information-sharing must be clear.
Structure · 7 sections- Contact Details
- Family Member Details
- Consent Basis
- Discussion
- Information Shared
- Information Withheld
- Follow-Up
Built for- Support Coordinator
- Case Manager
- Social Worker
- NDIS
SC Incident Note
Day-to-day safeguarding documentation for concerns that are short of NDIS Quality and Safeguards Commission reportable incidents but still warrant a discrete record. Captures observation, immediate action, decision about reportability, and follow-up.
Structure · 6 sections- Incident Details
- What Happened
- Observations
- Immediate Action
- Reportability Decision
- Follow-Up
Built for- Support Coordinator
- Case Manager
- Social Worker
- Disability Support Worker
- NDIS
SC Reportable Incident
NDIS Quality and Safeguards Commission reportable incident documentation aligned to the QSC reporting framework. Supports completion of the formal QSC reportable incident notification — this template does not replace the QSC portal submission, it generates the underlying record. Compliance-critical: confirm wording against current QSC guidance and use under organisational supervision.
Structure · 9 sections- Notification Details
- Participant Details
- Incident Category
- What Happened
- Witnesses
- Immediate Response
- Notifications Made
- Investigation Status
- Outcome
Built for- Support Coordinator
- Case Manager
- NDIS
SC Crisis Response Note
Documentation for acute crisis events requiring rapid Support Coordinator response — mental health crisis, housing crisis, family violence escalation, provider failure with safety implications. Captures trigger, risk assessment, actions taken, services contacted, outcome, and post-crisis plan.
Structure · 8 sections- Crisis Details
- Trigger
- Risk Assessment
- Actions Taken
- Services Contacted
- Outcome
- Post-Crisis Plan
- Debrief
Built for- Support Coordinator
- Case Manager
- Social Worker
- Youth Worker
- NDIS
SC Restrictive Practice Note
Documentation when a Support Coordinator becomes aware of restrictive practices being used in relation to a participant. Restrictive practices are heavily regulated by NDIS QSC and state-based authorisation panels — this template captures the practice, its authorisation status, triggers, response, and follow-up. Compliance-critical: verify authorisation status under the applicable state framework and confirm reporting against current QSC guidance.
Structure · 7 sections- Practice Details
- Authorisation Status
- Triggers
- Duration & Frequency
- Participant Response
- Less-Restrictive Alternatives
- Action Required
Built for- Support Coordinator
- Case Manager
- NDIS
Specialist SC Assessment
Assessment by a Specialist Support Coordinator (Level 3) of a complex case, documenting complexity factors, multi-system context, coordination challenges, and specialist recommendations. Used by Level 3 SCs to justify their distinct coordination work and to set the case formulation for the engagement.
Structure · 7 sections- Assessment Details
- Complexity Factors
- Multi-System Context
- Coordination Challenges
- Risk Profile
- Specialist Approach
- Recommendations
Built for- Support Coordinator
- Case Manager
- Social Worker
- NDIS
Capacity-Building Coordination Note
Documents the capacity-building component of Support Coordination — where the SC is teaching the participant (or family) to coordinate their own supports over time. This is the "teach to fish" work that justifies SC funding being time-limited rather than permanent.
Structure · 7 sections- Session Details
- Capacity-Building Goal
- Skill Being Built
- Activities
- Participant Response
- Generalisation
- Next Step
Built for- Support Coordinator
- Case Manager
- Social Worker
- Modality
CBT Session Note
Cognitive Behavioural Therapy session note with thought records, behavioural experiments, and homework.
Structure · 7 sections- Agenda
- Mood Check
- Homework Review
- Session Content
- Thought Record
- Behavioural Experiments
- Homework Set
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Psychotherapist
- +10 more
- Modality
ACT Session Note
Session note grounded in Acceptance and Commitment Therapy. Tracks work across the six hexaflex processes — defusion, acceptance, present-moment contact, self-as-context, values, and committed action — alongside the client's relationship with experiential avoidance and chosen valued domains. Suits psychologists and therapists practising ACT.
Structure · 6 sections- Values Explored
- Defusion Exercises
- Acceptance Work
- Mindfulness
- Committed Action
- Homework
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Psychotherapist
- +11 more
- Modality
Schema Therapy Session Note
Schema Therapy session note documenting schema modes, limited reparenting, and imagery work.
Structure · 6 sections- Schema Modes
- Mode Shifts
- Therapeutic Techniques
- Limited Reparenting
- Imagery Work
- Homework
Built for- Psychologist
- Clinical Psychologist
- Psychotherapist
- Counsellor
- +5 more
- Modality
IFS Session Note
Internal Family Systems session note documenting parts work, unburdening, and Self-leadership.
Structure · 6 sections- Parts Identified
- Target Part
- Unburdening
- Self-Leadership
- System Update
- Next Steps
Built for- Psychologist
- Clinical Psychologist
- Psychotherapist
- Counsellor
- +5 more
- Modality
CFT Session Note
Session note in the Compassion Focused Therapy framework. Documents work with the three affect-regulation systems (threat, drive, soothing), self-criticism and shame patterns, compassionate-mind imagery, and progress on building soothing-system capacity. Designed for clinicians using CFT with shame-based or self-critical presentations.
Structure · 5 sections- Affect Regulation Systems
- Compassionate Mind Training
- Imagery Exercises
- Self-Compassion Practice
- Homework
Built for- Psychologist
- Clinical Psychologist
- Psychotherapist
- Counsellor
- +5 more
- Modality
DBT Session Note
Dialectical Behaviour Therapy session note covering mindfulness, distress tolerance, emotion regulation, and interpersonal skills.
Structure · 6 sections- Diary Card Review
- Target Behaviours
- Skills Module
- Skills Practice
- Chain Analysis
- Homework
Built for- Psychologist
- Clinical Psychologist
- Psychotherapist
- Social Worker
- +8 more
- Modality
EMDR Session Note
Session note for EMDR therapy structured around Shapiro's eight-phase protocol. Tracks target memory, negative and positive cognitions, SUDS and VOC ratings, the desensitisation set used, and any installation, body scan, and closure work. Suits trauma-informed clinicians delivering structured EMDR.
Structure · 7 sections- Target Memory
- SUDS Rating
- VOC Rating
- Desensitisation
- Installation
- Body Scan
- Closure
Built for- Psychologist
- Clinical Psychologist
- Psychotherapist
- Counsellor
- +5 more
- Modality
CBT-I Session Note
CBT for Insomnia session note covering sleep hygiene, stimulus control, and sleep restriction.
Structure · 6 sections- Sleep Diary Review
- Sleep Efficiency
- Session Focus
- Behavioural Strategies
- Cognitive Restructuring
- Sleep Window
Built for- Psychologist
- Clinical Psychologist
- General Practitioner
- Counsellor
- +5 more
- Modality
Narrative Therapy Session
Narrative Therapy note focusing on externalising conversations, re-authoring stories, and identifying unique outcomes.
Structure · 6 sections- Problem Story
- Externalising Conversations
- Unique Outcomes
- Re-authoring
- Witnessing
- Homework
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +9 more
- Modality
SFBT Session Note
Solution-Focused Brief Therapy note utilising the miracle question, scaling questions, and exception finding.
Structure · 6 sections- Best Hopes
- Miracle Question
- Scaling Questions
- Exceptions
- Compliments
- Next Steps
Built for- Counsellor
- Social Worker
- Psychologist
- Clinical Psychologist
- +12 more
- Modality
Psychodynamic Psychotherapy
Psychodynamic session note exploring unconscious processes, transference, and defense mechanisms.
Structure · 6 sections- Free Association
- Transference/Countertransference
- Defense Mechanisms
- Dream Analysis
- Interpretations
- Plan
Built for- Psychotherapist
- Psychologist
- Clinical Psychologist
- Psychiatrist
- +3 more
- Modality
Play Therapy Session
Child-centered play therapy note documenting play themes, toys used, and child-therapist interaction.
Structure · 6 sections- Play Themes
- Toys/Activities
- Emotional Regulation
- Child-Therapist Relationship
- Limit Setting
- Parent Feedback
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +10 more
- Modality
Art Therapy Session
Art therapy session note focused on creative expression, media used, and symbolic processing.
Structure · 6 sections- Art Materials
- Creative Process
- Artwork Description
- Themes & Symbols
- Client Reflection
- Therapeutic Interventions
Built for- Counsellor
- Psychotherapist
- Psychologist
- Clinical Psychologist
- +10 more
- Modality
Gestalt Therapy Session
Gestalt therapy note focusing on here-and-now awareness, contact, and experiments like the empty chair.
Structure · 6 sections- Here-and-Now Awareness
- Contact Boundary
- Unfinished Business
- Experiments
- Body Awareness
- Integration
Built for- Psychotherapist
- Counsellor
- Psychologist
- Clinical Psychologist
- +4 more
- Modality
Motivational Interviewing
Motivational Interviewing note tracking change talk, sustain talk, and readiness for change.
Structure · 6 sections- Target Behaviour
- Stage of Change
- Change Talk
- Sustain Talk
- OARS Skills Used
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +17 more
- Modality
Interpersonal Therapy (IPT)
Interpersonal Psychotherapy note focusing on grief, role disputes, role transitions, or interpersonal deficits.
Structure · 6 sections- Problem Area Focus
- Recent Interpersonal Events
- Mood & Symptoms
- Communication Analysis
- Role Playing
- Homework
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Counsellor
- +5 more
- Modality
EFT Couples Therapy
Session note for Emotionally Focused Therapy with couples. Maps the negative interactional cycle, identifies primary versus secondary emotions, traces underlying attachment needs and injuries, and tracks within-session enactments and progress through the EFT stages. For couples therapists trained in EFT.
Structure · 6 sections- Cycle Tracking
- Primary Emotions
- Secondary Emotions
- Attachment Needs
- De-escalation
- Restructuring
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +5 more
- Modality
Gottman Method Couples
Gottman Method couples therapy note addressing the Sound Relationship House and conflict management.
Structure · 6 sections- Four Horsemen
- Conflict Management
- Love Maps/Fondness
- Shared Meaning
- Interventions
- Homework
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +5 more
- Modality
Eating Disorder Session Note
Structured session note for eating disorder treatment covering food behaviours, body image, medical monitoring, and therapeutic interventions.
Structure · 8 sections- Session Details
- Current Presentation
- Food and Eating Behaviours
- Body Image and Weight
- Medical Monitoring
- Therapeutic Interventions
- Risk Assessment
- Plan
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Counsellor
- +8 more
- Modality
Grief and Loss Session Note
Session note for grief and bereavement counselling including loss details, grief responses, and therapeutic support.
Structure · 8 sections- Session Details
- Loss Information
- Current Grief Presentation
- Grief Responses
- Therapeutic Interventions
- Support and Coping
- Risk Assessment
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +13 more
- Modality
Trauma-Focused CBT (TF-CBT) Session Note
Structured session note for Trauma-Focused CBT with children and adolescents, covering PRACTICE components.
Structure · 6 sections- Session Details
- TF-CBT Component
- Trauma Narrative Progress
- Parent/Carer Component
- Risk Assessment
- Plan
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +9 more
- Document
Professional Letter / Correspondence
Unified professional letter template for referrals, GP correspondence, school letters, employer letters, and provider emails. The AI adapts content and confidentiality level based on the recipient.
Structure · 6 sections- Recipient Details
- Client Summary
- Clinical Information
- Recommendations / Request
- Collaboration
- Closing
Built for- General Practitioner
- Psychologist
- Clinical Psychologist
- Psychiatrist
- +29 more
- Document
Client Session Summary
Warm, client-friendly summary of the session for the client's reference.
Structure · 5 sections- Session Overview
- Key Insights
- Progress
- Takeaways
- Action Items
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +16 more
- Document
Progress / Insurance Report
Formal progress report for referrers, insurers, or funding bodies. Includes optional insurance-specific sections for clinical necessity, ICD codes, and claim details.
Structure · 7 sections- Client Details
- Diagnosis
- Presenting Issues
- Treatment Summary
- Progress
- Clinical Necessity
- Recommendations
Built for- Psychologist
- Clinical Psychologist
- Speech Pathologist
- Occupational Therapist
- +13 more
- Document
Discharge Summary
Discharge summary closing out an episode of care. Captures presenting concerns, treatment delivered, outcomes and current functioning, risk status, recommendations, and follow-up arrangements with other providers. Written in the format GPs, referring clinicians, and external services expect when care is being handed back.
Structure · 6 sections- Client Details
- Reason for Referral
- Treatment Provided
- Outcomes
- Discharge Plan
- Follow-Up
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Social Worker
- +20 more
- Document
Treatment Plan Summary
Formal treatment plan document covering diagnoses, biopsychosocial formulation, treatment goals (with measurable indicators), proposed interventions, expected duration, and review points. Designed to share with the client, GP, or third parties (insurers, NDIS, schools) as a clinical roadmap rather than a session note.
Structure · 6 sections- Diagnoses
- Formulation
- Short-term Goals
- Long-term Goals
- Interventions
- Review
Built for- Psychologist
- Clinical Psychologist
- Social Worker
- Counsellor
- +13 more
- Document
Medical / WorkCover Certificate
Certificate of capacity for fitness for work, study, or WorkCover purposes. Includes optional workers compensation fields for claim number, mechanism of injury, and functional limitations.
Structure · 7 sections- Patient Details
- Date of Examination
- Diagnosis
- Fitness Statement
- Work Capacity
- Treatment Plan
- Review Date
Built for- General Practitioner
- Psychiatrist
- Physiotherapist
- Psychologist
- +11 more
- Document
Medico-Legal Report
Independent medico-legal report for court, tribunal, insurer, or workers-compensation purposes. Structured around the referrer's questions: history, examination, diagnosis, causation, prognosis, capacity, and reasoned clinical opinion. Written in the formal, defensible style required for medico-legal use.
Structure · 7 sections- Instructions
- Background
- Assessment
- Clinical Findings
- Opinion
- Prognosis
- Declaration
Built for- Psychiatrist
- Psychologist
- Clinical Psychologist
- General Practitioner
- +11 more
- Document
Clinical Supervision Record
Record of clinical supervision session documenting case review, skill development, and self-care.
Structure · 6 sections- Session Focus
- Cases Discussed
- Ethical Issues
- Skill Development
- Wellbeing/Self-Care
- Action Items
Built for- Psychologist
- Clinical Psychologist
- Social Worker
- Counsellor
- +16 more
- Document
Peer Supervision Record
Record of peer consultation or group supervision sessions — capturing the cases discussed (de-identified), reflections and feedback received, learning points, and any action items. Useful as evidence for AHPRA CPD requirements and supervision logbooks.
Structure · 5 sections- Participants
- Case/Topic
- Reflections
- Feedback/Recommendations
- Learning Outcomes
Built for- Psychologist
- Clinical Psychologist
- Social Worker
- Counsellor
- +9 more
- Document
Critical Incident Report
Formal reporting of a serious incident, responding actions, and organisational notification.
Structure · 7 sections- Incident Details
- People Involved
- Immediate Response
- Witness Accounts
- Outcome
- Notifications
- Review
Built for- Social Worker
- Nurse Practitioner
- Case Manager
- Mental Health Nurse
- +12 more
- Document
Letter of Support for Accommodations
Neuroaffirming letter framing accommodations as environmental modifications, referencing the Disability Discrimination Act 1992.
Structure · 6 sections- Recipient Details
- Clinician Statement
- Neurodivergent Profile
- Functional Impact in Context
- Recommended Accommodations
- Review
Built for- Psychologist
- Clinical Psychologist
- Occupational Therapist
- Psychiatrist
- +7 more
- Document
Neuroaffirming School Support Letter
Strengths-based letter for schools describing how a student learns best, classroom adjustments, and communication preferences organised by context.
Structure · 6 sections- Student Profile
- Learning Strengths
- Support Needs in School Environment
- Recommended Classroom Adjustments
- Communication Preferences
- Collaboration
Built for- Psychologist
- Clinical Psychologist
- Occupational Therapist
- Speech Pathologist
- +6 more
- Document
GP Letter (Brief / First Session)
Brief letter to referring GP following initial consultation, confirming attendance, presenting concerns, and initial plan.
Structure · 7 sections- Recipient Details
- Re: Client
- Attendance Confirmation
- Presenting Concerns
- Initial Impression
- Treatment Plan
- Closing
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +16 more
- Document
GP Letter (Progress / MHTP Review)
Progress letter to GP for Mental Health Treatment Plan review, summarising treatment to date, outcomes, and recommendations for further sessions.
Structure · 9 sections- Recipient Details
- Re: Client
- Sessions Attended
- Treatment Summary
- Outcome Measures
- Current Presentation
- Risk
- Recommendations
- Closing
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +13 more
- Document
Diagnosis Confirmation Letter
Formal letter confirming a clinical diagnosis for GP, school, employer, or other agencies requiring documentation.
Structure · 8 sections- Recipient Details
- Re: Client
- Assessment Context
- Diagnosis
- Diagnostic Criteria Met
- Functional Impact
- Recommendations
- Closing
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Paediatrician
- +6 more
- Document
Disability Support Pension (DSP) Supporting Letter
Supporting letter for Centrelink Disability Support Pension applications documenting diagnosis, functional impact, treatment history, and prognosis.
Structure · 8 sections- Recipient Details
- Re: Client
- Professional Relationship
- Diagnosis
- Functional Impact
- Treatment History
- Prognosis
- Closing
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Social Worker
- +6 more
- Document
WorkSafe Victoria Psychology Progress Report (PS604)
Structured progress report aligned with WorkSafe Victoria PS604 form requirements for psychological injury claims.
Structure · 9 sections- Worker Details
- Claim Details
- Diagnosis
- Treatment Summary
- Current Presentation
- Functional Capacity
- Return to Work
- Treatment Plan
- Certification
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +1 more
- Document
WorkSafe Victoria Initial Psychology Report (PS109)
Initial psychological report for WorkSafe Victoria claims covering assessment, diagnosis, treatment plan, and work capacity.
Structure · 10 sections- Worker Details
- Referral
- Assessment
- History
- Clinical Findings
- Diagnosis
- Functional Impact
- Treatment Plan
- Return to Work
- Certification
Built for- Psychologist
- Clinical Psychologist
- Document
WorkCover Queensland Progress Report
WorkCover Queensland progress report for psychological injury claims. Documents diagnosis, work-related causation, current symptoms and functional impact, treatment provided, response, capacity for work (graduated return-to-work where applicable), and ongoing recommendations. Aligned with WorkCover Queensland reporting expectations.
Structure · 8 sections- Worker Details
- Claim Details
- Diagnosis
- Treatment Progress
- Current Presentation
- Work Capacity
- Ongoing Treatment
- Declaration
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +3 more
- Document
NSW SIRA Allied Health Recovery Request
Template aligned with NSW SIRA requirements for allied health treatment requests in workers compensation and CTP claims.
Structure · 7 sections- Claimant Details
- Insurer Details
- Diagnosis
- Treatment Request
- Recovery Goals
- Work Capacity
- Declaration
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +7 more
- MDT / Hospital
MDT Meeting Minutes
Multi-disciplinary team meeting minutes documenting case discussions, decisions, and action items.
Structure · 5 sections- Attendees
- Cases Discussed
- Key Decisions
- Action Items
- Next Meeting
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Social Worker
- +11 more
- MDT / Hospital
Case Conference Note
Structured case conference note for multi-provider meetings about an individual client. Captures attendees and roles, the case formulation discussed, agreed care plan and provider responsibilities, risk and safeguarding decisions, and review date. Suitable for MBS case conference items and for shared-care documentation across services.
Structure · 6 sections- Participants
- Client Summary
- Discussion Points
- Agreed Plan
- Responsibilities
- Review Date
Built for- Social Worker
- Psychologist
- Clinical Psychologist
- Occupational Therapist
- +13 more
- MDT / Hospital
Ward Round Note
Inpatient ward round entry capturing interval progress since the last review, current MSE/clinical status, observations and investigations, medication changes, response and side effects, and the day's plan. Matches the structure registrars and consultants expect on the chart for psychiatric and medical inpatient teams.
Structure · 6 sections- Patient Details
- Overnight Review
- Mental State
- Physical Health
- Team Discussion
- Plan
Built for- Psychiatrist
- Mental Health Nurse
- Psychologist
- Clinical Psychologist
- +16 more
- MDT / Hospital
Consultation-Liaison Note
Consultation-liaison note for psychiatry or psychology services in a general hospital. Documents the referring team's question, relevant medical context, mental state and risk, formulation, recommendations to the parent team, and any handover to community services on discharge. Built for the inpatient C-L workflow.
Structure · 6 sections- Referral Reason
- Background
- Assessment
- Formulation
- Recommendations
- Follow-Up
Built for- Psychiatrist
- Psychologist
- Clinical Psychologist
- Mental Health Nurse
- +4 more
- MDT / Hospital
Discharge Planning Note
Multi-disciplinary discharge planning documentation for inpatient-to-community transitions.
Structure · 6 sections- Patient Details
- Admission Summary
- Discharge Readiness
- Community Supports
- Follow-Up Plan
- Contingency
Built for- Social Worker
- Occupational Therapist
- Mental Health Nurse
- Psychologist
- +9 more
- MDT / Hospital
Care Coordination Note
Care coordination contact log for activities outside direct client sessions — phone calls with other providers, advocacy, referrals, transitions, and inter-agency follow-up. Records who was contacted, the purpose, decisions made, and next steps. Useful where care coordination time is billable or auditable (NDIS, public mental health, case management).
Structure · 6 sections- Client Details
- Services Involved
- Coordination Actions
- Barriers
- Agreed Plan
- Next Steps
Built for- Social Worker
- Case Manager
- Occupational Therapist
- Nurse Practitioner
- +10 more
- MDT / Hospital
ISBAR Clinical Handover
Australian national standard clinical handover format (ACSQHC) for shift changes, unit transfers, and clinician escalation.
Structure · 5 sections- Identification
- Situation
- Background
- Assessment
- Recommendation
Built for- Mental Health Nurse
- Nurse Practitioner
- Psychiatrist
- Social Worker
- +12 more
- MDT / Hospital
Family Meeting Note
Documentation for family meetings involving consent for information sharing, shared decision-making, and family dynamics observations.
Structure · 6 sections- Attendees
- Purpose
- Information Shared
- Family Questions
- Decisions Made
- Follow-Up
Built for- Social Worker
- Psychologist
- Clinical Psychologist
- Psychiatrist
- +10 more
- MDT / Hospital
CMHT Review Note
Community mental health team review using recovery-oriented framework, including legal status, structured risk assessment, and step-up/step-down decisions.
Structure · 6 sections- Consumer Details
- Clinical Review
- Risk Assessment
- Recovery Goals
- Care Plan Update
- Frequency of Contact
Built for- Psychiatrist
- Mental Health Nurse
- Psychologist
- Clinical Psychologist
- +8 more
- MDT / Hospital
Rehabilitation Team Meeting Note
Structured rehabilitation MDT meeting documentation with functional outcome measures (FIM/Barthel), discipline-specific updates, and discharge planning.
Structure · 7 sections- Patient Details
- Discipline Updates
- FIM/Outcome Scores
- Goal Progress
- Barriers
- Discharge Planning
- Action Items
Built for- Physiotherapist
- Occupational Therapist
- Speech Pathologist
- Social Worker
- +9 more
- MDT / Hospital
Perinatal MDT Review
Perinatal mental health team review covering maternal mental health, mother-infant relationship, EPDS scores, and child safety considerations.
Structure · 6 sections- Mother Details
- Perinatal Stage
- Mental Health Assessment
- Mother-Infant Relationship
- Risk Factors
- Support Plan
Built for- Psychiatrist
- Psychologist
- Clinical Psychologist
- Mental Health Nurse
- +8 more
- MDT / Hospital
Pain Service MDT Note
Persistent pain MDT documentation with biopsychosocial formulation, functional goals, and medication rationalisation.
Structure · 6 sections- Patient Details
- Pain Assessment
- Discipline Reviews
- Functional Goals
- Medication Review
- Treatment Plan
Built for- Psychologist
- Clinical Psychologist
- Physiotherapist
- Nurse Practitioner
- +7 more
- Education
IEP/ILP Progress Note
Individual Education/Learning Plan progress note documenting goal achievement and adjustments.
Structure · 5 sections- Student Details
- IEP Goals
- Progress Update
- Adjustments
- Next Review
Built for- School Counsellor
- Educational Psychologist
- Teacher
- Special Education Teacher
- Education
Student Progress Report
Formal progress report for parents, school leadership, or external providers. Captures the student's starting point, goals or targets, progress since the last report, evidence of growth, areas needing further support, and recommended next steps. Suits termly reporting cycles and external review.
Structure · 6 sections- Student Details
- Assessment Summary
- Progress
- Strengths
- Areas for Development
- Recommendations
Built for- School Counsellor
- Educational Psychologist
- Speech Pathologist
- Education
NCCD Evidence Record
Evidence record for the Nationally Consistent Collection of Data on School Students with Disability (NCCD). Documents the imputed disability category, level of adjustment, the adjustments provided across categories (curriculum, environment, communication, personal care), and the evidence base sustaining each — built for census-time review and audit.
Structure · 6 sections- Student Details
- Disability Category
- Level of Adjustment
- Evidence of Adjustment
- Impact
- Review
Built for- School Counsellor
- Teacher
- Special Education Teacher
- Education
Curriculum Differentiation
Documentation of how curriculum has been adjusted for an individual student — content, process, product, or environment differentiation — with the rationale, the strategies in place, and how their effectiveness will be reviewed. Useful evidence for NCCD, IEPs, and learning support team meetings.
Structure · 6 sections- Student Details
- Learning Needs
- Differentiation Strategies
- Resources
- Assessment Modifications
- Review
Built for- Teacher
- Special Education Teacher
- Educational Psychologist
- Education
Classroom Observation
Structured classroom observation capturing the context of the lesson, the student's engagement and behaviour over time, peer interactions, work output, environmental factors, and a brief interpretation. Suits learning-support, wellbeing, and behaviour referrals as the evidence base for next-step planning.
Structure · 6 sections- Student Details
- Observation Context
- Behaviour Observed
- Engagement
- Peer Interactions
- Recommendations
Built for- School Counsellor
- Educational Psychologist
- Psychologist
- Education
Behaviour Incident Report
Behaviour incident record covering antecedents, the behaviour itself (described objectively), consequences, response by staff, impact on others, follow-up with the student and family, and any restorative or behaviour-support actions. Designed to feed positive behaviour support data and meet school incident-reporting requirements.
Structure · 7 sections- Student Details
- Incident Description
- Antecedent
- Behaviour
- Consequence
- Actions Taken
- Follow-Up
Built for- School Counsellor
- Teacher
- Youth Worker
- Education
Parent Meeting Summary
Summary of a parent or carer meeting — who attended, what was discussed, decisions or agreements reached, follow-up actions and timelines, and any concerns raised that need referral or escalation. Use after wellbeing, learning-support, or behaviour conversations so the record matches what was agreed in the room.
Structure · 5 sections- Attendees
- Purpose
- Discussion Points
- Agreed Actions
- Follow-Up
Built for- School Counsellor
- Teacher
- Educational Psychologist
- Education
School Counselling Session
Counselling session note adapted for the school context. Captures presenting concerns, the conversation and intervention, mood and risk where relevant, agreed plan, and any liaison with teachers, year coordinators, or external clinicians. Designed for school counsellors, psychologists, and wellbeing staff working under school confidentiality limits.
Structure · 6 sections- Student Details
- Presenting Concern
- Session Content
- Strategies Discussed
- Plan
- Parent/Teacher Liaison
Built for- School Counsellor
- Education
School Group Program Note
Session note for school-based group programs — social skills, anxiety management, friendship, resilience, and similar curricula. Captures group composition, the session's focus and activities, individual student engagement and observations, and any safeguarding actions. Useful record for program evaluation and individual student files.
Structure · 6 sections- Program Details
- Session Topic
- Activities
- Student Participation
- Observations
- Next Session
Built for- School Counsellor
- Psychologist
- Social Worker
- Education
SSG Meeting Minutes
Student Support Group meeting minutes documenting collaborative planning for students with additional needs.
Structure · 6 sections- Attendees
- Student Details
- Review of Goals
- Current Concerns
- Agreed Actions
- Next Meeting
Built for- School Counsellor
- Teacher
- Special Education Teacher
- Education
Intervention Session Note
Session note for literacy, numeracy, or other targeted learning interventions (1:1 or small group).
Structure · 6 sections- Session Details
- Focus Area
- Activities
- Student Response
- Progress
- Next Session
Built for- Learning Support Teacher
- Special Education Teacher
- Teacher
- Education
Learning Support Referral Note
Documentation for referring a student into learning support programs with background and evidence.
Structure · 6 sections- Student Details
- Referral Reason
- Background
- Assessments
- Strategies Tried
- Recommendations
Built for- Learning Support Teacher
- Teacher
- Special Education Teacher
- Year Level Coordinator
- Education
Structured Reading Intervention Session
Session note for structured literacy and reading intervention programs (1:1 or small group).
Structure · 6 sections- Session Details
- Familiar Reading
- Running Record
- Letter/Word Work
- Writing
- New Book Introduction
Built for- Learning Support Teacher
- Teacher
- Education
Functional Behaviour Assessment
Structured Functional Behaviour Assessment (FBA) documenting behaviour patterns, antecedents, and functions.
Structure · 7 sections- Student Details
- Target Behaviour
- Setting Events
- Antecedents
- Consequences
- Hypothesised Function
- Recommendations
Built for- Behaviour Specialist
- School Counsellor
- School Psychologist
- Special Education Teacher
- Education
Behaviour Support Plan Review
Review meeting notes for an existing Behaviour Support Plan — progress, adjustments, and next steps.
Structure · 6 sections- Student Details
- Attendees
- Current BSP Summary
- Progress Review
- Adjustments
- Next Review
Built for- Behaviour Specialist
- School Counsellor
- Special Education Teacher
- Year Level Coordinator
- Education
Restorative Practice Conference
Notes from a restorative justice conference or circle addressing harm and rebuilding relationships.
Structure · 6 sections- Conference Details
- Participants
- What Happened
- Impact
- Agreements
- Follow-Up
Built for- Behaviour Specialist
- School Counsellor
- Year Level Coordinator
- Student Wellbeing Officer
- Education
Re-entry / Return Meeting
Re-entry meeting record for a student returning from suspension, exclusion, or extended absence. Captures attendees, the student's reflections, supports and adjustments agreed for the return, expectations and check-in plan, and any external supports being engaged. Designed to anchor a structured, restorative re-entry.
Structure · 6 sections- Student Details
- Attendees
- Reason for Absence
- Discussion
- Conditions
- Support Plan
Built for- Behaviour Specialist
- Year Level Coordinator
- Student Wellbeing Officer
- School Counsellor
- Education
EAL/D Student Assessment
English as an Additional Language/Dialect student assessment and language proficiency record.
Structure · 5 sections- Student Details
- Language Background
- Proficiency Assessment
- Learning Needs
- Support Plan
Built for- Esl Teacher
- Teacher
- Learning Support Teacher
- Education
Language Development Progress Record
Progress record for English as an Additional Language or Dialect (EAL/D) students. Tracks the student's development across listening, speaking, reading, and writing — alongside curriculum access, classroom adjustments, and any home-language supports. Aligns with EAL/D progression frameworks used by Australian schools.
Structure · 6 sections- Student Details
- Period
- Listening & Speaking
- Reading
- Writing
- Recommendations
Built for- Esl Teacher
- Teacher
- Learning Support Teacher
- Education
Student Health Assessment
Health screening or assessment record for a student, including vision, hearing, and general health.
Structure · 6 sections- Student Details
- Assessment Type
- Findings
- Actions
- Referrals
- Follow-Up
Built for- School Nurse
- Student Wellbeing Officer
- Education
First Aid Incident Record
Documentation of a first aid event including injury/illness details, treatment, and notifications.
Structure · 6 sections- Student Details
- Incident
- Assessment
- Treatment
- Notifications
- Outcome
Built for- School Nurse
- Teacher
- Student Wellbeing Officer
- Education
Individual Health Care Plan
Health care plan for a student with an ongoing medical condition requiring management at school.
Structure · 7 sections- Student Details
- Medical Condition
- Daily Management
- Emergency Response
- Medication
- Communication
- Review
Built for- School Nurse
- Student Wellbeing Officer
- Education
Career Counselling Session
Session note for career counselling interviews covering aspirations, pathways, and action planning.
Structure · 6 sections- Student Details
- Session Purpose
- Interests & Strengths
- Pathways Discussion
- Action Plan
- Follow-Up
Built for- Careers Counsellor
- School Counsellor
- Year Level Coordinator
- Education
Work Experience Placement Note
Documentation for work experience placements including employer feedback and student reflection.
Structure · 6 sections- Student Details
- Placement Details
- Preparation
- Employer Feedback
- Student Reflection
- Outcomes
Built for- Careers Counsellor
- Year Level Coordinator
- Teacher
- Education
Subject Selection / Pathways Meeting
Record of a subject-selection or pathways meeting with the student and/or parents. Captures interests and strengths, post-school goals (university, VET, apprenticeship, employment), prerequisites and ATAR considerations, recommended subject combinations, and follow-up actions. Useful audit trail for careers and senior-school staff.
Structure · 6 sections- Student Details
- Attendees
- Current Performance
- Pathway Goals
- Subject Selections
- Recommendations
Built for- Careers Counsellor
- Year Level Coordinator
- School Counsellor
- Education
Attendance Follow-up Record
Documentation of attendance concern follow-up conversations with students and/or families.
Structure · 6 sections- Student Details
- Attendance Data
- Contact Details
- Discussion
- Actions
- Follow-Up
Built for- Attendance Officer
- Year Level Coordinator
- Student Wellbeing Officer
- School Counsellor
- Education
Attendance Improvement Plan
Attendance improvement plan covering current attendance data, contributing factors, agreed targets, the strategies and supports being put in place (school, family, external), responsible staff, and review dates. Designed for attendance officers, year-level coordinators, and student welfare teams managing chronic absence.
Structure · 6 sections- Student Details
- Current Attendance
- Barriers
- Targets
- Strategies
- Review
Built for- Attendance Officer
- Year Level Coordinator
- Student Wellbeing Officer
- Education
Student Welfare Review
Welfare review meeting notes documenting concerns across academic, social, and personal domains.
Structure · 6 sections- Student Details
- Attendees
- Concerns
- Current Supports
- Risk Assessment
- Actions
Built for- Year Level Coordinator
- Student Wellbeing Officer
- School Counsellor
- Education
Student Check-in Note
Lightweight check-in note for short, scheduled or drop-in wellbeing conversations. Captures the focus of the conversation, mood and any risk noted, what support was offered, and whether a follow-up is needed. Designed for high-volume, low-friction logging by wellbeing teams and chaplains.
Structure · 5 sections- Student Details
- Check-in Context
- Conversation Summary
- Wellbeing Rating
- Actions
Built for- Year Level Coordinator
- Student Wellbeing Officer
- School Counsellor
- Teacher
- Education
Transition Support Note
Documentation for students transitioning between schools, year levels, or from primary to secondary.
Structure · 6 sections- Student Details
- Transition Type
- Current Status
- Support Needs
- Handover Information
- Plan
Built for- Year Level Coordinator
- Student Wellbeing Officer
- School Counsellor
- Learning Support Teacher
- Education
Peer Observation / Coaching Note
Peer observation record for professional learning, coaching cycles, and collegial feedback.
Structure · 6 sections- Observation Details
- Focus Area
- Observations
- Strengths
- Discussion Points
- Next Steps
Built for- Teacher
- Learning Support Teacher
- Esl Teacher
- Special Education Teacher
- +1 more
- Education
Schools Therapy / Allied Health Session
Session note for allied health professionals (OT, speech, psychology) working within school settings.
Structure · 6 sections- Session Details
- Student Presentation
- Session Content
- Classroom Observations
- Collaboration
- Plan
Built for- Occupational Therapist
- Speech Pathologist
- Psychologist
- Clinical Psychologist
- +9 more
- Education
Schools Case Conference / Parent Meeting
Record for school-based case conferences and parent meetings involving multiple staff and/or external providers.
Structure · 6 sections- Meeting Details
- Attendees
- Student Overview
- Discussion
- Actions
- Next Meeting
Built for- School Counsellor
- Teacher
- Special Education Teacher
- Learning Support Teacher
- +4 more
- Education
School Recommendations Report
Report providing recommendations for a student to the school, covering classroom strategies, accommodations, and support needs.
Structure · 8 sections- Student Details
- Assessment Summary
- Key Findings
- Classroom Recommendations
- Assessment Accommodations
- Wellbeing Recommendations
- Home Recommendations
- Review
Built for- Psychologist
- Educational Psychologist
- School Counsellor
- Occupational Therapist
- +3 more
- Assessment
ADHD Assessment Summary
Structured summary report for ADHD diagnostic assessments including rating scales and clinical interview.
Structure · 6 sections- Referral Information
- Developmental History
- Rating Scales
- Clinical Interview
- Diagnostic Impression
- Recommendations
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Paediatrician
- +5 more
- Assessment
Autism Assessment Summary
Structured summary report for autism diagnostic assessments including ADOS/ADI observations.
Structure · 6 sections- Referral Information
- Developmental History
- Assessment Instruments
- Behavioural Observations
- Diagnostic Impression
- Support Recommendations
Built for- Psychologist
- Clinical Psychologist
- Paediatrician
- Speech Pathologist
- +5 more
- Assessment
Psychoeducational Assessment
Comprehensive psychoeducational assessment report covering cognitive and academic functioning.
Structure · 7 sections- Referral Information
- Background
- Cognitive Assessment
- Academic Assessment
- Behavioural Observations
- Summary
- Recommendations
Built for- Educational Psychologist
- Psychologist
- Clinical Psychologist
- Neuropsychologist
- +1 more
- Assessment
Speech-Language Assessment
Speech and language assessment report covering receptive, expressive, and pragmatic communication.
Structure · 7 sections- Client Details
- Referral Reason
- Assessment Instruments
- Receptive Language
- Expressive Language
- Pragmatics
- Recommendations
Built for- Speech Pathologist
- Assessment
Developmental Assessment
Developmental assessment report covering key domains for early childhood and paediatric settings.
Structure · 8 sections- Child Details
- Developmental History
- Assessment Methods
- Motor Development
- Communication
- Social-Emotional
- Cognitive
- Recommendations
Built for- Paediatrician
- Psychologist
- Clinical Psychologist
- Occupational Therapist
- +6 more
- Assessment
Cognitive Assessment
Neuropsychological or cognitive assessment report documenting intellectual and cognitive functioning.
Structure · 7 sections- Referral Information
- Background
- Assessment Instruments
- Cognitive Profile
- Behavioural Observations
- Summary
- Recommendations
Built for- Neuropsychologist
- Psychologist
- Clinical Psychologist
- Educational Psychologist
- +3 more
- Assessment
Home Exercise Program
Home exercise program for clients to complete between sessions. Each exercise includes purpose, technique cues, sets/reps/duration, frequency, equipment needed, progression criteria, and red flags. Suits physiotherapy, exercise physiology, and any rehab discipline issuing structured between-session work.
Structure · 7 sections- Client Details
- Goals
- Exercise List
- Instructions
- Precautions
- Progression Criteria
- Review Date
Built for- Physiotherapist
- Exercise Physiologist
- Occupational Therapist
- Chiropractor
- +4 more
- Assessment
Safety Plan
Stanley-Brown style safety plan for clients at risk of suicide or acute crisis. Documents personal warning signs, internal coping strategies, social distractions, supportive people, professional and crisis contacts, and means restriction. Designed to be co-created with the client and given to them as a usable plan.
Structure · 7 sections- Warning Signs
- Coping Strategies
- Social Supports
- Professional Contacts
- Emergency Contacts
- Environment Safety
- Reasons for Living
Built for- Psychologist
- Clinical Psychologist
- Counsellor
- Social Worker
- +13 more
- Assessment
Sensory Profile Report
Occupational therapy sensory profile report. Captures sensory processing patterns across modalities (auditory, visual, tactile, vestibular, proprioceptive, oral), the functional impact across home, school, and community settings, and recommended sensory strategies. Suitable for paediatric and autism-related referrals.
Structure · 6 sections- Assessment Tool
- Sensory Preferences
- Registration/Seeking
- Sensitivity/Avoiding
- Functional Impact
- Strategies
Built for- Occupational Therapist
- Assessment
Swallowing Assessment
Speech Pathology dysphagia assessment covering oral mechanism, trials, and recommendations.
Structure · 6 sections- History
- Oral Mechanism Exam
- Food/Fluid Trials
- Signs of Aspiration
- Diagnosis
- Diet Recommendations
Built for- Speech Pathologist
- Assessment
Voice Assessment
Speech pathology voice assessment covering perceptual analysis (quality, pitch, loudness, resonance), respiratory and phonatory behaviours, vocal hygiene, occupational voice demands, and impact on participation. Includes recommendations for therapy or onward referral. Suits adult and paediatric voice caseloads.
Structure · 6 sections- History
- Perceptual Analysis
- Acoustic Measures
- Aerodynamic Measures
- Laryngeal Function
- Recommendations
Built for- Speech Pathologist
- Assessment
Gait Analysis Report
Physiotherapy gait analysis report. Documents observational gait phases, spatial-temporal parameters, deviations and compensations, joint kinematics, biomechanical contributors, and the link to functional impact. Concludes with intervention recommendations — gait retraining, footwear, orthotics, or assistive devices.
Structure · 7 sections- History
- Observation
- Gait Cycle Analysis
- Muscle Function
- Range of Motion
- Assistive Devices
- Plan
Built for- Physiotherapist
- Exercise Physiologist
- Podiatrist
- Orthopaedic Surgeon
- Assessment
Capacity Assessment
Assessment of decision-making capacity regarding finances, lifestyle, or medical treatment.
Structure · 7 sections- Reason for Assessment
- Cognitive Functioning
- Understanding Information
- Retention
- Weighing Options
- Communicating Decision
- Opinion
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Psychiatrist
- +6 more
- Assessment
Forensic Risk Assessment
Forensic psychological risk assessment for court, parole, or correctional referrers. Covers presenting offence, history (criminogenic and clinical), structured risk formulation (e.g. HCR-20, RSVP, Static-99R domains where relevant), protective factors, treatment recommendations, and risk-management considerations. Written in the formal, defensible style expected by courts and tribunals.
Structure · 7 sections- Legal Context
- Offending History
- Clinical Interview
- Risk Assessment Tools
- Protective Factors
- Risk Formulation
- Recommendations
Built for- Psychologist
- Clinical Psychologist
- Psychiatrist
- Forensic Psychologist
- +2 more
- Assessment
Vocational Assessment
Vocational assessment for return-to-work, NDIS, or rehabilitation purposes. Covers work history and qualifications, current functional capacity, transferable skills, barriers (medical, psychological, environmental), labour-market considerations, vocational goals, and recommended next steps (training, support, graduated return-to-work). Suits rehabilitation counsellors, OTs, and vocational psychologists.
Structure · 6 sections- Work History
- Education/Skills
- Physical Capacity
- Psychological Barriers
- Transferable Skills
- Vocational Goals
Built for- Rehabilitation Counsellor
- Occupational Therapist
- Psychologist
- Clinical Psychologist
- +4 more
- Assessment
Neuroaffirming Diagnostic Report (Autism/ADHD)
Strengths-based neurodevelopmental assessment report using neuroaffirming language aligned with APS position statements and Autism CRC guidelines.
Structure · 7 sections- Personal Profile & Strengths
- Referral Context
- Neurodevelopmental History
- Assessment Methods
- Neurocognitive Profile
- Diagnostic Formulation
- Support Recommendations
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Paediatrician
- +3 more
- Assessment
Late-Identified Adult Autism Report
Neuroaffirming assessment report for late-identified autistic adults, addressing masking, compensation, burnout history, and post-diagnostic identity support.
Structure · 7 sections- Personal Context
- Journey to Assessment
- Masking & Compensation
- Neurocognitive Profile
- Sensory Experiences
- Diagnostic Formulation
- Post-Diagnostic Support
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Psychiatrist
- +1 more
- Assessment
Developmental History Interview (Parent/Caregiver)
Comprehensive developmental history interview guide for gathering information from parents or caregivers prior to child assessment.
Structure · 8 sections- Referral Information
- Pregnancy & Birth
- Developmental Milestones
- Medical History
- Family History
- Social & Emotional
- Education
- Current Concerns
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Educational Psychologist
- +7 more
- Assessment
ADHD Clinical Interview with Parent/Carer
Structured parent/carer interview for ADHD assessment covering DSM-5 symptom domains, onset, pervasiveness, and functional impact.
Structure · 7 sections- Presenting Concerns
- Inattention Symptoms
- Hyperactivity-Impulsivity
- Onset & Pervasiveness
- Functional Impact
- Differential Considerations
- Collateral Information
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Educational Psychologist
- +3 more
- Assessment
Autism Clinical Interview with Parent/Carer
Structured parent/carer interview for autism assessment covering social communication, restricted/repetitive behaviours, sensory profile, and developmental history.
Structure · 7 sections- Presenting Concerns
- Early Development
- Social Communication
- Restricted & Repetitive Behaviours
- Sensory Profile
- Functional Impact
- Differential Considerations
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Educational Psychologist
- +5 more
- Assessment
Child/Adolescent Intake Assessment (with Parent/Carer)
General intake assessment for children and adolescents covering presenting concerns, developmental history, family context, and treatment planning — suitable for psychology, counselling, and allied health.
Structure · 8 sections- Presenting Concerns
- Developmental History
- Family & Social
- Education
- Mental Health Screen
- Risk Assessment
- Formulation
- Plan
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Educational Psychologist
- +11 more
- Assessment
Adult ADHD Clinical Interview
Structured clinical interview for adult ADHD assessment covering childhood onset, current symptom presentation, functional impact, and differential considerations.
Structure · 7 sections- Presenting Concerns
- Childhood Symptoms
- Current Inattention
- Current Hyperactivity-Impulsivity
- Functional Impact
- Differential Considerations
- Diagnostic Impression
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Psychiatrist
- +3 more
- Assessment
Autism Clinical Interview for Adult Diagnosis
Structured clinical interview for adult autism assessment covering social communication, restricted/repetitive behaviours, sensory profile, masking, and developmental history.
Structure · 8 sections- Presenting Concerns
- Developmental History
- Social Communication
- Restricted & Repetitive Behaviours
- Sensory Experiences
- Masking & Compensation
- Functional Impact
- Differential Considerations
Built for- Psychologist
- Clinical Psychologist
- Neuropsychologist
- Psychiatrist
- +1 more
- Assessment
Neuropsychological Assessment Session
Structured record for neuropsychological test administration sessions, including tests administered, behavioural observations, and validity indicators.
Structure · 6 sections- Session Details
- Tests Administered
- Behavioural Observations
- Validity Indicators
- Preliminary Observations
- Plan
Built for- Neuropsychologist
- Clinical Psychologist
- Psychologist
- Educational Psychologist
- +1 more
- Assessment
Neuropsychology Feedback Session
Record for neuropsychological assessment feedback sessions with client, family, and/or referrer.
Structure · 6 sections- Session Details
- Attendees
- Results Shared
- Client/Family Response
- Recommendations Discussed
- Plan
Built for- Neuropsychologist
- Clinical Psychologist
- Psychologist
- Educational Psychologist
- +1 more
- Assessment
Neuropsychology Pre-Assessment Interview
Comprehensive clinical interview conducted prior to neuropsychological testing, gathering history and contextualising the referral question.
Structure · 11 sections- Interview Details
- Referral Information
- Presenting Concerns
- Developmental History
- Medical History
- Psychiatric History
- Educational/Occupational History
- Social History
- Current Functioning
- Behavioural Observations
- Assessment Plan
Built for- Neuropsychologist
- Clinical Psychologist
- Psychologist
- Educational Psychologist
- +1 more
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Templates for Every Profession
Grounded Scribe includes 185 note templates spanning 70+ professions, including SOAP notes, DAP notes, mental health progress notes, GP management plans, MBS-compliant formats with pre-filled item numbers, NDIS progress notes, and therapy-modality templates for CBT, DBT, ACT, and more. Practitioners can also create custom templates or generate new ones by uploading samples of their own notes.
Mental Health
Psychologists, Counsellors, Social Workers, Psychotherapists
Medical
GPs, Psychiatrists, Paediatricians, Nurse Practitioners
Allied Health
OTs, Speech Pathologists, Physiotherapists, Dietitians
Education
School Counsellors, Educational Psychologists, Teachers
Support
Youth Workers, Case Managers, Peer Support Workers
Specialist
Exercise Physiologists, Aged Care Workers, Researchers
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Understanding note formats — SOAP, DAP, BIRP, and PROC
Each progress-note format has its own clinical logic. SOAP separates reported from observed data; DAP streamlines for psychotherapy; BIRP / GIRP / PIRP anchor the note to a behaviour, goal, or problem; PROC names an explicit session objective and evaluates goal attainment. Our practitioner's guide compares all four — when each one shines, where they overlap, and how to choose.
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