Document withClarity, Compassion,and Clinical Precision
Psychological care requires deep insight—and accurate, compliant documentation. From intake evaluations to progress notes and treatment planning, your records must reflect clinical reasoning, therapeutic intent, and patient safety.
Clinical Excellence: The SCRIBE AI Psychologist Template is designed to help you capture your sessions with empathy and structure, built on best practices in mental health documentation.
🧾 Why a Psychologist Template Matters
Your notes are more than records—they're a legal document, a clinical compass, and a collaborative communication tool. The right structure saves time, reduces liability, and enhances care outcomes.
Streamlined session documentation
SOAP, DAP, or narrative formats with built-in structure
Clinical reasoning support
Built-in structure for treatment planning and therapeutic intent
Risk documentation
Comprehensive suicidality and safety planning documentation
Insurance-ready formats
CPT alignment for seamless billing and compliance
👥 Who Uses This Template?
Clinical Psychologists
(PhD, PsyD)
Counseling Psychologists
Licensed Practitioners
Neuropsychologists
Cognitive Assessment
Behavioral Health Providers
Integrated Care
School & Forensic Psychologists
Specialized Settings
Private Practice & Clinics
All Settings
🧩 Inside the Psychologist Template
SCRIBE AI's Psychologist Template blends flexibility with clinical rigor, supporting structured therapy documentation without interfering with therapeutic flow.
Identifying Information
Basic demographic and administrative info (auto-filled where integrated with EHR)
Key Components:
- Name, age, gender
- Date of service
- Provider name & credentials
- Session number (e.g., 4 of 12)
Presenting Problem / Reason for Visit
What brings the client to therapy today?
Example:
"Client reports increased anxiety and disrupted sleep after recent job loss."
History & Background
Relevant mental health, medical, family, and trauma history
Key Components:
- Psychiatric diagnoses (past/current)
- Previous therapy or medication use
- Substance use history
- Support systems or psychosocial context
Mental Status Examination (MSE)
Observational data recorded during the session
Key Components:
- Appearance & behavior
- Mood and affect
- Thought content/process
- Insight and judgment
- Attention, memory, orientation
Example:
"Oriented x3, cooperative, affect restricted, thought process linear, denies SI/HI."
Therapy Session Content
What was discussed or observed in-session?
Key Components:
- Subjective: Client's own report—mood, experiences, triggers
- Objective: Therapist observations—affect, body language, engagement
Example:
"Client described feelings of hopelessness. Tearful at times. Difficulty identifying positive coping skills."
Clinical Assessment
Professional interpretation of session dynamics, progress, or diagnostic updates
Key Components:
- Clinical impression
- Diagnostic criteria (if changed/updated)
- Response to current treatment
- Risk factors (suicidality, self-harm, violence)
Plan / Treatment Strategy
Outline the goals, interventions, and next steps
Key Components:
- Therapy modality used (CBT, DBT, ACT, etc.)
- Homework or practice assigned
- Crisis plan or safety agreement
- Progress toward existing treatment goals
- Frequency and duration of future sessions
Example:
"Continue CBT with focus on cognitive restructuring. Assign thought journal. Reassess suicidality next session."
🚫Common Pitfalls in Psychology Notes
🧪 Use Case Examples
Anxiety Therapy Session
Depression Follow-Up
Trauma Therapy
✅Best Practices for Psychologist Documentation
- ✓Use specific behavioral language (not just 'client seems better')
- ✓Record diagnostic rationale and DSM-5 alignment when applicable
- ✓Include therapeutic technique used
- ✓Be concise but clinically meaningful
- ✓Always document risk levels and safety plans
🛡️Legal & Ethical Compliance
SCRIBE AI supports psychologists in maintaining:
- ✓HIPAA and ethical documentation standards
- ✓Clear risk documentation (SI, HI, abuse reporting)
- ✓CPT coding alignment (e.g., 90834, 90837, 90791)
- ✓Insurance audit readiness
- ✓Progress tracking for goal-oriented therapy
Simplify Therapy Notes with SCRIBE AI
SCRIBE AI gives psychologists structured, AI-guided tools to enhance your documentation workflow
Real-time charting
Chart in real time or post-session with efficiency
Modality templates
Use note templates for different modalities or diagnoses
Reduced cognitive load
Reduce cognitive load and documentation time
Defensible records
Protect yourself with accurate and defensible records
Try the Psychologist Template Now
Therapeutic work deserves documentation that is clear, protective, and purposeful. Focus on care—not clerical work—while ensuring your notes meet clinical, legal, and ethical standards.
Conclusion
Therapeutic work deserves documentation that is clear, protective, and purposeful. The SCRIBE AI Psychologist Template helps you focus on care—not clerical work—while ensuring your notes meet clinical, legal, and ethical standards.
Document with intention. Practice with confidence. Use SCRIBE AI.