Record (or dictate) after the session → get structured notes in your style.
Use it for in-person or telehealth sessions — keep your workflow the same, just spend less time charting.
INITIAL INTAKE ASSESSMENT (MENTAL HEALTH) Client: [Name] Date: [MM/DD/YYYY] Session type: Initial intake Presenting concerns: - [Client’s words / brief context] - [Duration, triggers, current impact] Current symptoms (as reported): - Mood: [e.g., low / anxious / irritable] - Sleep: [e.g., onset, maintenance, quality] - Appetite/energy: [notes] Functional impact: - Work/school: [brief] - Relationships: [brief] - Daily routines: [brief] History (high-level): - Prior therapy: [yes/no, brief] - Medications: [if shared] - Relevant medical history: [if shared] Protective factors: - [Support system / strengths / coping tools] Plan (draft): - Goals for next 2–4 weeks: [bullets] - Homework: [optional] - Next session: [date/time placeholder]
Create consistent notes and summaries without making clinical claims—just clean documentation you can review and edit.
Generate a structured note from your dictation, aligned to your preferred format and wording.
Capture updates and next steps in a repeatable structure you can refine before saving.
Create a client-ready recap focused on what was discussed and agreed—no medical promises.
Everything is editable and meant to support documentation—always review before use.
D — Data Client reported increased work stress and difficulty unwinding in the evenings. Discussed recent conflict with a colleague and the impact on sleep routine. A — Assessment Themes: stress management, boundaries, and sleep hygiene. Client engaged and reflective; identified one situation to practice a new boundary script. P — Plan - Practice the boundary script in a low-stakes situation this week. - Continue tracking evening routine (what helps / what interferes). - Next session: review outcomes and refine coping plan.
S — Subjective Client described feeling “on edge” after a challenging week and noted less consistency with planned coping routines. O — Objective Client was punctual, attentive, and participated throughout the session. Affect appeared consistent with stated mood. A — Assessment Reviewed triggers and patterns. Explored one alternative interpretation of the conflict and rehearsed a grounding technique. P — Plan - Continue grounding technique practice (2 minutes, once daily). - Set one boundary-related goal and record results. - Next session: review goal progress and update plan as needed.
Session summary (client-ready) Today we talked about stress at work and how it has affected your evenings. We identified one boundary you want to try and practiced what you might say. We also discussed a short grounding exercise to use when you feel tense. Next steps - Try the boundary script once this week. - Practice the grounding exercise daily. - Notice what helps your evening routine and what gets in the way.
Use only statements that are true for your system. The copy below is written to be accurate-by-default and easy to adjust.
You can request deletion of documents and audio recordings at any time.
Build your own note template so outputs match your documentation style and the structure you actually use.
Define sections once → reuse them across sessions → edit anytime.
For patient-facing specialists who want less paperwork.
You will get free minutes to use.
For solo practitioners who want more time with patients.
For small clinics that want less admin and more care.
For healthcare organisations with large teams.
Flexible billing. Depends on number of practitioners.
Short answers to the common questions.
