The Complete Clinical Note Taking Templates have been fully updated and expanded to 47 pages, offering a clear, structured, and ethically compliant system for documenting clinical work.
Designed for psychologists and mental health clinicians, this resource supports you to meet professional standards while strengthening your clinical reasoning and streamlining the note taking process.
High quality notes are not just an administrative requirement. They are a clinical tool. This bundle is structured to help you document what matters, stay aligned with AHPRA expectations, and maintain clear, defensible, and meaningful records across all stages of therapy. Each template includes prompts that guide your thinking, support accurate formulation, and help you track progress and decision-making over time.
What’s Included
Initial Assessment Template
A comprehensive framework for first sessions, with prompts that help you gather essential information without missing clinically relevant details. This template supports you to build a nuanced understanding of the client’s history, presenting concerns, risk, and therapeutic goals while establishing a strong foundation for ongoing care.
Progress Notes Template (Revised and simplified)
Redesigned with clarity and usability in mind, this version removes the unnecessary complexity often seen in templates.
It provides a structure that helps you document session content, interventions, clinical observations, risk considerations, and goal-related progress in a concise and clinically meaningful way. Prompts also encourage reflective reasoning so your notes are not just descriptive, but purposeful and clinically defensible.
Final Session and Discharge Template
Termination requires careful and ethical documentation. This template supports you to summarise progress, communicate outcomes, document risk status, and outline ongoing recommendations. It ensures that your final notes are complete, clear, and aligned with professional requirements.
Optimised for the way you work
Every template is formatted so you can use it however you take notes – digitally on your computer, written directly on a tablet during sessions with an electronic pencil, or printed for handwritten notes. The layout is clean, intuitive, and built to support real clinical workflows, whether you prefer structured typing or pen-and-paper.
Key Features
• AHPRA-aligned guidance provided to support compliant, contemporaneous, and clinically relevant documentation
• Built-in supports to strengthen your clinical reasoning and decision-making
• Structured, easy-to-use layouts that streamline the writing process and reduce administrative load
• Practical for both print and digital use on tablet devices
• Designed to integrate seamlessly with case formulation and treatment planning processes
Whether you are refining your documentation practices or establishing a consistent system across your clinical work, this resource offers a clear and dependable framework that enhances quality and reduces cognitive load.
Purchase individually or as part of the Practice Tools Bundle for additional savings.
Complete Clinical Note Taking Templates
Note: This is a digital file. This resource and its contents are the intellectual property of Amanda Moses Psychology. Each purchase is for individual use only and for use with your clients. If you work in a group practice, each professional must purchase their own copy to use this product. There are strictly no refunds.
Please see the terms of purchase here, for your reference:
https://www.amandamosespsychology.com.au/terms-of-purchase
