These are prompts or statements that you can utilize in AutoNotes. Copy and paste into the session summary section. Feel free to customize as you see fit. Each section is labeled; however, the prompts may fit in other dimensions as well, simply by changing the topic.

For example: “Due to overwhelming anxiety, the client expressed concerns about their ability to manage daily responsibilities and social interactions.” Can be changed to: “Due to depressive symptoms, the client expressed concerns about their ability to manage daily responsibilities and social interactions.

Anxiety Prompts:

Trouble sleeping due to racing thoughts.

• The client reports a recent increase in heart palpitations and frequent feelings of restlessness.
• Due to overwhelming anxiety, the client expressed concerns about their ability to manage daily responsibilities and social interactions.
• Experiencing moderate to severe anxiety symptoms.
• Consistent worry, difficulty concentrating, sleep disturbances, and physical symptoms.
• Significantly impacts their daily functioning.
• Concerned about managing responsibilities.
• Concerned about social interactions.
• Provide the client with psychoeducation on anxiety.
• Implement CBT techniques to help the client identify and challenge negative thought patterns.
• Reframing anxious thoughts and replacing them with more realistic and positive alternatives.
• Gradually expose the client to anxiety-provoking situations or triggers in a controlled and supportive environment.
• Collaboratively develop an exposure hierarchy to address their fears systematically and gradually increase their tolerance to anxiety-inducing stimuli.
• Introduce stress management techniques such as mindfulness, meditation, and self-care practices.
• Guide the client in developing a personalized self-care routine that includes regular exercise, adequate sleep, and engaging in activities they find pleasurable.
• Discussed with the client the option of a referral to a psychiatrist for a medication evaluation.
• Collaborated with the client's primary care provider (psychiatrist) to determine if pharmacological intervention may be beneficial in managing their symptoms.

Depression Prompts:

The client presented with symptoms indicative of depression, as evidenced by the client's self-report of feeling persistently sad and hopeless and experiencing a loss of interest in activities they once enjoyed.

• The client expressed difficulty concentrating, low energy levels, and changes in appetite and sleep patterns.
• The client described feeling overwhelmed by negative thoughts, experiencing feelings of worthlessness, and having recurrent thoughts of death.
• Based on the client's self-report and observed behaviors, they appear to be experiencing moderate to severe depressive symptoms.
• The client's persistent sadness, loss of interest, changes in appetite and sleep patterns, and cognitive and physical symptoms align with the diagnostic criteria for major depressive disorder.
• The client's feelings of hopelessness, low self-worth, and suicidal ideation indicate the severity and potential risk associated with their depressive state.
• The therapist thoroughly assessed the client's current safety, including evaluating suicide risk.
• The therapist and client completed a safety plan with emergency contact information and strategies for managing suicidal thoughts.
• The safety plan includes identified support systems and resources the client can access during times of crisis.
• The therapist utilized Cognitive Behavioral Therapy (CBT) to help the client identify and challenge negative thought patterns, develop coping strategies, and improve problem-solving skills.
• Collaboratively developed a structured daily routine incorporating self-care activities, regular exercise, and building and maintaining social connections.
• The therapist encouraged the client to engage in activities they once found enjoyable, even if motivation is low, to increase positive experiences and combat depressive symptoms.
• Provided the client with information and resources for additional support with mutual support groups, hotlines, or online mental health platforms.
• The therapist encouraged the client to seek social support from trusted friends and family members.
• Discussed with the client the option of a referral to a psychiatrist for a medication evaluation.
• Collaborated with the client's primary care provider (psychiatrist) to determine if pharmacological intervention may be beneficial in managing their symptoms.
• Collaborated with the client to document their progress, thoughts, and emotions in between therapy sessions.
•  Encouraged using a mood journal or other self-monitoring tools to enhance self-awareness and facilitate discussion during therapy.

Substance Use Prompts:

In today’s session, the client presented with symptoms and behaviors consistent with substance use disorder.

• The client reported a long history of substance use, specifically struggling with alcohol addiction. 
• The client shared difficulties in controlling their drinking, experiencing cravings, and engaging in excessive alcohol consumption despite negative consequences. 
• The client expressed feelings of guilt, shame, and a desire to regain control over their life.
• Based on the client's self-report and observed behaviors, it is evident that they are facing significant challenges related to Opioid addiction, indicating a substance use disorder.
• The client’s expressed desire to regain control and feelings of guilt and shame highlight the emotional impact of their addiction.
• The therapist provided the client with psychoeducation about substance use disorder, including addiction's physiological and psychological effects.
• The therapist educated the client on the stages of change and the recovery process, emphasizing the importance of commitment and motivation.
• The therapist utilized motivational interviewing techniques to explore the client's ambivalence about their substance use and enhance their motivation for change.
• The therapist assisted the client in identifying and exploring their personal values and goals, connecting them to the benefits of sobriety and recovery.
• The client and therapist collaboratively developed a relapse prevention plan to identify triggers, high-risk situations, and coping strategies to manage cravings and urges. 
• The therapist agreed to teach the client skills for coping with stress, boredom, and social pressures without turning to alcohol or other illicit substances.
• The therapist encouraged the client to engage in mutual support groups such as Alcoholics Anonymous (AA) or other peer support programs. 
• The therapist and client discussed the importance of building a strong support network of individuals who understand their struggles and can provide ongoing encouragement and accountability.
• The client will continue individual therapy sessions to explore underlying psychological factors contributing to the client's substance use disorder. 
• The session addressed co-occurring mental health conditions, such as anxiety or depression, and developing strategies to manage these conditions without turning to alcohol or other illicit substances.
• Discussed the potential benefit of additional services, such as medical detoxification, inpatient or outpatient treatment programs, or counseling services specifically tailored to substance use disorders. 
• The therapist recommended collaborating with other professionals and treatment providers as necessary.

PTSD Prompts:

The therapist utilized the evidence-based treatment for PTSD, cognitive processing therapy (CPT).

• The therapist utilized the evidence-based treatment for PTSD, prolonged exposure therapy (PE). 
• The therapist utilized evidence-based treatment for PTSD, eye movement desensitization, and reprocessing (EMDR).
• Discuss how individual therapy for PTSD assisted during the session in processing traumatic memories and managing symptoms.
• Investigated with the client how mutual support groups can aid individuals with PTSD by providing a supportive community of peers with similar experiences.
• Reflected on the role of medication in managing PTSD symptoms, the types of medications often used, and their effectiveness.
• Discussed the importance of self-care practices and lifestyle changes in conjunction with therapy and medication to manage PTSD.
• Examined the importance of family support and therapy in the recovery process of a person with PTSD.
• Explored the long-term impact of continuous treatment on PTSD symptoms and overall quality of life.
• Evaluated the role of mindfulness practices, such as meditation or yoga, as adjunctive treatments for PTSD.
• Discussed how trauma-informed care addresses the specific needs of individuals with PTSD and improves treatment outcomes.

Suicidal & Homicidal Ideations:

Suicidal Ideation:

History of Suicidal Ideation: "The patient has a history of suicidal ideation, with previous episodes reported around times of significant stress or during depressive episodes. Regular screening and continuous mental health support are crucial for this individual to manage potential triggers and symptoms."

No History of Suicidal Ideation: The patient has no history of suicidal ideation. The therapist will continue regular mental health check-ups and assessments monthly or as needed to help monitor their emotional well-being and detect any possible changes in their mental health status early."

Current Screening: The patient was screened today using the Columbia-Suicide Severity Rating Scale (C-SSRS) to assess suicidal ideation and behavior. The client is a Low-Risk, Moderate Risk, High Risk.

Outcome of Screening: 

• The patient expressed occasional thoughts of death but denied any active suicidal planning or intent. It's recommended that the patient continues with their current mental health treatment plan and that any changes in their condition are reported promptly.
• The patient disclosed recurrent thoughts of suicide but denied having a specific plan or intent. Regular follow-ups, enhanced therapeutic support, and possibly a safety plan are strongly recommended.
• The patient revealed having a plan for suicide but without a defined intent to act on it. This high-risk situation requires immediate crisis intervention and potential hospitalization for the patient's safety.
• The patient expressed both a specific plan and intent to commit suicide. This critical situation necessitates immediate safety measures, including hospitalization and potential notification of family members or other support systems, while abiding by confidentiality regulations.
• The patient exhibited passive suicidal ideation, expressing wishes to 'not wake up' or 'not be here anymore,' but without a specific plan or intent. While less immediate than active ideation, this still calls for increased therapeutic support, safety planning, and regular monitoring.

Homicidal Ideation:

History of Homicidal Ideation: The patient has a history of homicidal ideation, often reported during periods of intense anger or frustration. Close monitoring, crisis intervention, and ongoing therapy are vital for this patient to manage their emotions safely and effectively.

No History of Homicidal Ideation: The patient has no history of homicidal ideation. However, regular mental health assessments can help promptly detect and address any potential negative thoughts or feelings.

Current Screening: The patient was assessed today for homicidal ideation using a structured clinical interview.

Outcome of Screening: 

• The patient reported no current thoughts of violence toward others. Their risk is currently considered low. However, consistent mental health support and regular follow-ups are recommended to monitor their status.
• The patient disclosed recurrent thoughts of violence toward others but denied having a specific plan or intent. Regular follow-ups, increased therapeutic support, and possibly a safety plan are recommended.
• The patient revealed a specific plan to harm someone without a defined intent to act on it. This high-risk situation requires immediate crisis intervention, potentially involving law enforcement for the safety of the potential victim(s).
• The patient expressed both a specific plan and intent to cause harm to others. This immediate crisis situation necessitates emergency measures, including potential hospitalization and notification of law enforcement, while respecting confidentiality laws.
• The patient exhibited passive homicidal ideation, expressing general thoughts of harm toward others but without specific plans or intentions. Although less immediate than active ideation, this calls for increased therapeutic support, safety planning, and regular monitoring.

Rationale to Continue Treatment Prompts:

Depression:

• Explore how maintaining mental health treatment can aid in managing and possibly reducing depressive episodes as a rationale to continue treatment.
• Describe how continued therapy can help cultivate coping mechanisms for times of heightened stress or sadness as a rationale to continue treatment.
• Investigate the relationship between consistent mental health treatment and the likelihood of relapse in depression as a rationale to continue treatment.
• Discuss how ongoing mental health treatment can improve life quality and increase daily task functionality as a rationale to continue treatment.

Anxiety:

• Evaluate how maintaining mental health treatment can support in managing anxiety symptoms and panic attacks as a rationale to continue treatment.
• Consider the benefits of a steady treatment plan in building resilience to anxiety triggers as a rationale to continue treatment.
• Discuss the role of ongoing treatment in teaching relaxation techniques, such as deep breathing and mindfulness, as a rationale for continuing treatment.
• Explain how consistent therapy can help alleviate chronic worry and fears, contributing to a more balanced life as a rationale to continue treatment.

Substance Use Disorders:

• Discuss the role of sustained treatment in preventing relapse in substance use disorders as a rationale to continue treatment.
• Detail how continued treatment can provide essential support during periods of craving or withdrawal as a rationale to continue treatment.
• Investigate the impact of long-term therapy and medication (where appropriate) on changing habitual patterns of substance use as a rationale to continue treatment.
• Explain the value of ongoing mental health treatment in rebuilding personal relationships and social connections that may have been damaged by substance use as a rationale to continue treatment.

PTSD:

• Reflect on how consistent mental health treatment can aid in processing traumatic memories and reducing symptoms of PTSD as a rationale to continue treatment.
• Elucidate the importance of ongoing therapy in building a toolbox of coping strategies for when triggers or flashbacks occur as a rationale to continue treatment.
• Evaluate how maintaining treatment can help re-establish a sense of control and improve overall well-being as a rationale to continue treatment.
• Discuss the role of long-term mental health treatment in fostering resilience and post-traumatic growth as a rationale for continuing treatment.

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