Initial Assessment
Comprehensive intake assessment covering presenting concerns, history, risk, and treatment goals.
Generate this note from a recording or dictation
Free — 10 sessions per month, no credit card required.
Template structure
The initial assessment template captures these sections automatically from your recording.
- 1Presenting Concerns
- 2History
- 3Mental State Examination
- 4Risk Assessment
- 5Formulation
- 6Treatment Goals
Comparing this format to others? See SOAP, DAP, BIRP, and PROC compared.
Built for
How it works
- 1
Record or dictate the session
In-person, telehealth, or hybrid. Audio is deleted immediately after transcription — never stored.
- 2
Pick the Initial Assessment template
Or set it as your default for this session type so future recordings use it automatically.
- 3
Review and finalise
Your note is generated in the structure above. Edit anything you want — your practice, your voice — then save to the client record.
More clinical 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.
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.
Try the Initial Assessment template free
10 sessions per month on the free tier. Upgrade anytime from $19/month + GST for more sessions, longer recordings, and unlimited dictations.