Initial Assessment

• Template structure

  The Initial Assessment template captures these sections automatically from your recording.

  1. Presenting Concerns
  2. History
  3. Mental State Examination
  4. Risk Assessment
  5. Formulation
  6. Treatment Goals

  Comparing this format to others? See SOAP, DAP, BIRP, and PROC compared.

• Built for

  • Psychologist
  • Clinical Psychologist
  • Psychiatrist
  • Counsellor
  • Social Worker
  • Psychotherapist
  • Mental Health Nurse
  • Nurse Practitioner
  • Occupational Therapist
  • Speech Pathologist
  • Physiotherapist
  • Dietitian
  • School Counsellor
  • School Psychologist
  • Youth Worker
  • Case Manager
  • Addiction Counsellor
  • Marriage Counsellor
  • Family Therapist
  • Trauma Therapist
  • Sex Therapist
  • Rehabilitation Counsellor
  • Community Services Worker
  • Art Therapist
  • Music Therapist
  • Drama Therapist
  • Play Therapist
  • Exercise Physiologist
  • Forensic Psychologist
  • Sports Psychologist
  • Chiropractor
  • Osteopath
  • Naturopath

1. 01 Record or dictate the session

   In-person, telehealth, or hybrid. Audio is deleted immediately once it's processed. If it can't upload, it stays on your own device so you can retry; if it uploads but can't be processed, it's held in Australia for up to 48 hours, then deleted.

2. 02 Pick the Initial Assessment template

   Or make it your default template so future recordings use it automatically.

3. 03 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.

• SOAP NoteThe 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 NoteStreamlined 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 NoteDetailed narrative account of the therapeutic process, including therapist reflections and clinical observations.
• Session NoteGeneral-purpose session documentation suitable for a wide range of clinical and allied health encounters, including therapy sessions and treatment sessions.
• Case NoteBrief, 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.

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