Browse Our Note Template Library
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
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.
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.
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.
Process Note
Detailed narrative account of the therapeutic process, including therapist reflections and clinical observations.
Session Note
General-purpose session documentation suitable for a wide range of clinical and allied health encounters, including therapy sessions and treatment sessions.
Initial Assessment
Comprehensive intake assessment covering presenting concerns, history, risk, and treatment goals.
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.
Consultation Note
Documentation for specialist consultations, second opinions, and inter-professional referrals.
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.
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.
Welfare Concern Record
Documentation for welfare concerns, safeguarding observations, and duty of care reporting.
Psychosocial Assessment
Comprehensive assessment of psychosocial factors including living situation, supports, and barriers.
Group Session Note
Documentation for group therapy and group program sessions with participant-level observations.
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.
Comp. Suicide Risk Assessment
Detailed suicide risk formulation covering ideation, intent, plan, and protective factors.
Palliative Care Consultation
Holistic care note for palliative patients addressing physical, emotional, and spiritual needs.
AOD Comprehensive Assessment
Alcohol and Other Drugs assessment covering substance use history, dependence, and impacts.
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.
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.
Child Therapy Session Note (Brief)
Brief session note for child therapy including play-based and developmental observations, suitable for shorter sessions.
Child Therapy Session Note (Comprehensive)
Comprehensive child therapy note with detailed developmental, behavioural, and family observations for complex cases.
Psychiatric Medication Review
Structured note for psychiatric medication reviews covering current medications, side effects, efficacy, and changes.
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.)
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.
Access Request Report
Supporting evidence report for NDIS access requests, documenting disability and functional impact.
NDIS Progress Report
Progress report for NDIS plan reviews documenting goal achievement and ongoing support needs.
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.
Mealtime Management Report
Mealtime management assessment and recommendations for NDIS participants with swallowing or feeding needs.
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.
Assistive Technology Report
Comprehensive assistive technology assessment and recommendation report for NDIS participants.
NDIS Session Note
Session documentation linking therapy activities to NDIS plan goals and line items. Required for NDIS Commission audits.
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.
Plan Review Evidence Summary
Concise evidence summary for NDIS plan review meetings, aggregating goal achievement, funding utilisation, and recommendations for the next plan.
SIL Shift Note
Shift documentation for Supported Independent Living covering daily routines, health monitoring, behavioural observations, and handover.
NDIS Incident Report
NDIS Commission-compliant incident report with reportable incident classification, required timeframes, and follow-up actions.
Home Modification Report
Occupational Therapy report for NDIS Capital - Home Modifications funding covering structural modifications, functional assessment, and costings.
Transition Planning Report
NDIS transition planning for key life stages (school leaver, moving to SIL, ageing) covering gap analysis, stakeholder input, and milestone timelines.
Communication Assessment & AAC Recommendation
Speech Pathology assessment of communication needs with multimodal AAC feature matching, trial outcomes, and implementation plan.
NDIS Service Agreement
Service agreement template for NDIS participants outlining supports, costs, scheduling, and cancellation terms.
NDIS Incident Report (Quick)
Reportable incident template for NDIS registered providers. Must be submitted within 24 hours for serious incidents.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
CBT Session Note
Cognitive Behavioural Therapy session note with thought records, behavioural experiments, and homework.
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.
Schema Therapy Session Note
Schema Therapy session note documenting schema modes, limited reparenting, and imagery work.
IFS Session Note
Internal Family Systems session note documenting parts work, unburdening, and Self-leadership.
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.
DBT Session Note
Dialectical Behaviour Therapy session note covering mindfulness, distress tolerance, emotion regulation, and interpersonal skills.
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.
CBT-I Session Note
CBT for Insomnia session note covering sleep hygiene, stimulus control, and sleep restriction.
Narrative Therapy Session
Narrative Therapy note focusing on externalising conversations, re-authoring stories, and identifying unique outcomes.
SFBT Session Note
Solution-Focused Brief Therapy note utilising the miracle question, scaling questions, and exception finding.
Psychodynamic Psychotherapy
Psychodynamic session note exploring unconscious processes, transference, and defense mechanisms.
Play Therapy Session
Child-centered play therapy note documenting play themes, toys used, and child-therapist interaction.
Art Therapy Session
Art therapy session note focused on creative expression, media used, and symbolic processing.
Gestalt Therapy Session
Gestalt therapy note focusing on here-and-now awareness, contact, and experiments like the empty chair.
Motivational Interviewing
Motivational Interviewing note tracking change talk, sustain talk, and readiness for change.
Interpersonal Therapy (IPT)
Interpersonal Psychotherapy note focusing on grief, role disputes, role transitions, or interpersonal deficits.
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.
Gottman Method Couples
Gottman Method couples therapy note addressing the Sound Relationship House and conflict management.
Eating Disorder Session Note
Structured session note for eating disorder treatment covering food behaviours, body image, medical monitoring, and therapeutic interventions.
Grief and Loss Session Note
Session note for grief and bereavement counselling including loss details, grief responses, and therapeutic support.
Trauma-Focused CBT (TF-CBT) Session Note
Structured session note for Trauma-Focused CBT with children and adolescents, covering PRACTICE components.
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.
Client Session Summary
Warm, client-friendly summary of the session for the client's reference.
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.
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.
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.
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.
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.
Clinical Supervision Record
Record of clinical supervision session documenting case review, skill development, and self-care.
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.
Critical Incident Report
Formal reporting of a serious incident, responding actions, and organisational notification.
Letter of Support for Accommodations
Neuroaffirming letter framing accommodations as environmental modifications, referencing the Disability Discrimination Act 1992.
Neuroaffirming School Support Letter
Strengths-based letter for schools describing how a student learns best, classroom adjustments, and communication preferences organised by context.
GP Letter (Brief / First Session)
Brief letter to referring GP following initial consultation, confirming attendance, presenting concerns, and initial plan.
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.
Diagnosis Confirmation Letter
Formal letter confirming a clinical diagnosis for GP, school, employer, or other agencies requiring documentation.
Disability Support Pension (DSP) Supporting Letter
Supporting letter for Centrelink Disability Support Pension applications documenting diagnosis, functional impact, treatment history, and prognosis.
WorkSafe Victoria Psychology Progress Report (PS604)
Structured progress report aligned with WorkSafe Victoria PS604 form requirements for psychological injury claims.
WorkSafe Victoria Initial Psychology Report (PS109)
Initial psychological report for WorkSafe Victoria claims covering assessment, diagnosis, treatment plan, and work capacity.
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.
NSW SIRA Allied Health Recovery Request
Template aligned with NSW SIRA requirements for allied health treatment requests in workers compensation and CTP claims.
MDT Meeting Minutes
Multi-disciplinary team meeting minutes documenting case discussions, decisions, and action items.
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.
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.
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.
Discharge Planning Note
Multi-disciplinary discharge planning documentation for inpatient-to-community transitions.
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).
ISBAR Clinical Handover
Australian national standard clinical handover format (ACSQHC) for shift changes, unit transfers, and clinician escalation.
Family Meeting Note
Documentation for family meetings involving consent for information sharing, shared decision-making, and family dynamics observations.
CMHT Review Note
Community mental health team review using recovery-oriented framework, including legal status, structured risk assessment, and step-up/step-down decisions.
Rehabilitation Team Meeting Note
Structured rehabilitation MDT meeting documentation with functional outcome measures (FIM/Barthel), discipline-specific updates, and discharge planning.
Perinatal MDT Review
Perinatal mental health team review covering maternal mental health, mother-infant relationship, EPDS scores, and child safety considerations.
Pain Service MDT Note
Persistent pain MDT documentation with biopsychosocial formulation, functional goals, and medication rationalisation.
IEP/ILP Progress Note
Individual Education/Learning Plan progress note documenting goal achievement and adjustments.
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.
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.
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.
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.
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.
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.
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.
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.
SSG Meeting Minutes
Student Support Group meeting minutes documenting collaborative planning for students with additional needs.
Intervention Session Note
Session note for literacy, numeracy, or other targeted learning interventions (1:1 or small group).
Learning Support Referral Note
Documentation for referring a student into learning support programs with background and evidence.
Structured Reading Intervention Session
Session note for structured literacy and reading intervention programs (1:1 or small group).
Functional Behaviour Assessment
Structured Functional Behaviour Assessment (FBA) documenting behaviour patterns, antecedents, and functions.
Behaviour Support Plan Review
Review meeting notes for an existing Behaviour Support Plan — progress, adjustments, and next steps.
Restorative Practice Conference
Notes from a restorative justice conference or circle addressing harm and rebuilding relationships.
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.
EAL/D Student Assessment
English as an Additional Language/Dialect student assessment and language proficiency record.
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.
Student Health Assessment
Health screening or assessment record for a student, including vision, hearing, and general health.
First Aid Incident Record
Documentation of a first aid event including injury/illness details, treatment, and notifications.
Individual Health Care Plan
Health care plan for a student with an ongoing medical condition requiring management at school.
Career Counselling Session
Session note for career counselling interviews covering aspirations, pathways, and action planning.
Work Experience Placement Note
Documentation for work experience placements including employer feedback and student reflection.
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.
Attendance Follow-up Record
Documentation of attendance concern follow-up conversations with students and/or families.
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.
Student Welfare Review
Welfare review meeting notes documenting concerns across academic, social, and personal domains.
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.
Transition Support Note
Documentation for students transitioning between schools, year levels, or from primary to secondary.
Peer Observation / Coaching Note
Peer observation record for professional learning, coaching cycles, and collegial feedback.
Schools Therapy / Allied Health Session
Session note for allied health professionals (OT, speech, psychology) working within school settings.
Schools Case Conference / Parent Meeting
Record for school-based case conferences and parent meetings involving multiple staff and/or external providers.
School Recommendations Report
Report providing recommendations for a student to the school, covering classroom strategies, accommodations, and support needs.
ADHD Assessment Summary
Structured summary report for ADHD diagnostic assessments including rating scales and clinical interview.
Autism Assessment Summary
Structured summary report for autism diagnostic assessments including ADOS/ADI observations.
Psychoeducational Assessment
Comprehensive psychoeducational assessment report covering cognitive and academic functioning.
Speech-Language Assessment
Speech and language assessment report covering receptive, expressive, and pragmatic communication.
Developmental Assessment
Developmental assessment report covering key domains for early childhood and paediatric settings.
Cognitive Assessment
Neuropsychological or cognitive assessment report documenting intellectual and cognitive functioning.
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.
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.
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.
Swallowing Assessment
Speech Pathology dysphagia assessment covering oral mechanism, trials, and recommendations.
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.
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.
Capacity Assessment
Assessment of decision-making capacity regarding finances, lifestyle, or medical treatment.
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.
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.
Neuroaffirming Diagnostic Report (Autism/ADHD)
Strengths-based neurodevelopmental assessment report using neuroaffirming language aligned with APS position statements and Autism CRC guidelines.
Late-Identified Adult Autism Report
Neuroaffirming assessment report for late-identified autistic adults, addressing masking, compensation, burnout history, and post-diagnostic identity support.
Developmental History Interview (Parent/Caregiver)
Comprehensive developmental history interview guide for gathering information from parents or caregivers prior to child assessment.
ADHD Clinical Interview with Parent/Carer
Structured parent/carer interview for ADHD assessment covering DSM-5 symptom domains, onset, pervasiveness, and functional impact.
Autism Clinical Interview with Parent/Carer
Structured parent/carer interview for autism assessment covering social communication, restricted/repetitive behaviours, sensory profile, and developmental history.
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.
Adult ADHD Clinical Interview
Structured clinical interview for adult ADHD assessment covering childhood onset, current symptom presentation, functional impact, and differential considerations.
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.
Neuropsychological Assessment Session
Structured record for neuropsychological test administration sessions, including tests administered, behavioural observations, and validity indicators.
Neuropsychology Feedback Session
Record for neuropsychological assessment feedback sessions with client, family, and/or referrer.
Neuropsychology Pre-Assessment Interview
Comprehensive clinical interview conducted prior to neuropsychological testing, gathering history and contextualising the referral question.
Templates for Every Profession
Grounded Scribe includes over 100 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
Not sure which format suits you?
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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