Home > Note examples
Find exactly what you need for your practice and impress insurers!
Client and Therapy Type
From individuals, children, couples, to varied family sizes + specilized therapies such as EMDR
Whether it's intake, a myriad of progress notes (DAP, SOAP, PIRP, SIRP, GIRP, BIRP, PIE), or service interactions.
Convert session recordings, dictations, or direct text descriptions into structured notes.
Adapt each note by employing or discarding sections as per clinical requirements. Teach AI how to refer to you and your clients.
Craft notes across multiple therapeutic modalities. *Please note that all sample notes here are fictional and are not derived from a real life session.
Monitor therapeutic evolution, employing a host of templates to encapsulate the patient's therapeutic journey. Explore examples for each note type
Adjust and decide exactly what you want to include, creating a perfect fit for your therapeutic approach and individual client needs. Learn more here.
All our note templates are crafted with stringent standards to ensure they meet insurance compliance requirements.
Our notes are compliant
Blue Cross Blue Shield (BCBS) Mentalyc Notes captures all the details BCBS requires including the full client history, presenting issues, diagnostics, clinical formulation, interventions performed, care coordination, and future treatment plans. It also allows linkage of treatment to measurable goals.
Aetna necessitates clear documentation of medical necessity, diagnosis justification, symptom severity, care coordination, and progress monitoring. Mentalyc Notes facilitates capturing all of these elements concisely.
Medicare necessitates clear justification of medical necessity, risk assessments, care coordination details, diagnosis codes, measurable goals, and progress tracking. Mentalyc Notes prompts for comprehensive documentation across all these areas. Using it assists providers in meeting Medicare's documentation standards for medical need, appropriateness of care, and ongoing outcomes.
Medicaid requires establishment of symptoms and function impairments requiring treatment, use of evidence-based modalities, linkage of interventions to goals, risk evaluations, precise start/end times, and care coordination. Mentalyc Notes ensures easy documentation of these key elements in a Medicaid compliant structure. It facilitates rapid yet thorough capturing of clinical details Medicaid focuses on for reimbursement.
Mentalyc meticulously utilizes the industry-standard DSM-5 diagnostic criteria and codes, aligning with Anthem's commitment to recognized diagnostic criteria. Our notes diligently document a comprehensive clinical formulation that captures predisposing factors, adhering to Anthem's guidelines for a thorough assessment. Moreover, our notes encompass a detailed mental status examination and thorough risk assessment, meeting Anthem's requirements for a comprehensive evaluation. We ensure that our notes thoroughly outline the discussed goals and articulate a continued treatment plan, in full accordance with Anthem's care coordination and follow-up requirements.
Mentalyc notes capture subjective quotes from the client, illustrating symptoms and aligning with Centene's emphasis on the patient's perspective. They also record details on the onset, frequency, and duration of symptoms, providing crucial information in line with Centene's evaluation criteria. Furthermore, our notes include family history and trauma details where applicable, addressing Centene's assessment requirements and providing relevant context. Additionally, we document the interventions used and the client's response, ensuring compliance with Centene's standards for evidence-based care.
Mentalyc notes comprehensively cover all presenting problems, clinical observations, and diagnosis details in alignment with Humana's comprehensive care approach. Additionally, any safety risks or concerns identified are diligently noted as per Humana's risk assessment guidelines. Our notes outline the follow-up actions, such as assigned homework, in accordance with Humana's discharge planning and continuity of care protocols. Lastly, we emphasize the coordination of care with other providers, ensuring compliance with Humana's integrated care requirements.
HealthCare Services Corp. Mentalyc notes use industry-standard DSM-5 diagnoses and codes that align with HCSC's diagnostic criteria. We thoroughly document the interventions used and provide a clear rationale behind them, following HCSC's evidence-based care standards. Our notes also capture the progress made and any challenges faced, offering clinical evidence of outcomes as required by HCSC. Furthermore, we outline measurable goals using the S.M.A.R.T format, adhering to HCSC's treatment planning and efficacy criteria.
CVS Health Corp.
Mentalyc notes include a mental status exam that comprehensively assesses mood, speech, and cognition, meeting CVS's clinical evaluation guidelines. Important biological factors, such as medications and medical history, are noted to provide relevant clinical context as per CVS's criteria. We also record a clinical formulation that summarizes predisposing factors, complying with CVS's biopsychosocial assessment standards. Lastly, our notes outline follow-up actions, such as assigned homework, in accordance with CVS's care planning requirements.
GuideWell Mutual Holding Corp.
Mentalyc notes cover symptoms, functioning, and include related quotes from the client, effectively conveying patient experiences as per GuideWell's guidelines. Our notes identify diagnostic possibilities with clinical reasoning, meeting GuideWell's standards for evidence-based diagnoses. They also document risk assessments for safety concerns, addressing GuideWell's safety evaluation guidelines. Lastly, we outline goals, barriers, and continued treatment plans in compliance with GuideWell's care planning criteria.
Independence Health Group Inc.
Mentalyc notes document mental status exam details like mood, speech, and cognition are included to provide a comprehensive clinical evaluation as required by Independence Health Group. Our notes identify diagnoses with clinical reasoning and examples, meeting Independence Health Group's criteria for evidence-based assessment. They also document symptoms, onset, duration, frequency, and intensity, offering a detailed understanding of the client's condition. Lastly, we outline goals in S.M.A.R.T format and barriers, addressing Independence Health Group's treatment planning and monitoring protocols.
Mentalyc notes cover clinical observations, diagnoses, and symptoms clearly, providing a comprehensive overview of the client's condition as required by Kaiser Permanente. We note interventions used and the client's response, offering insights into the effectiveness of the provided care. Our notes assess strengths, risks, and safety concerns appropriately, following Kaiser Permanente's comprehensive evaluation standards. Lastly, we outline coordinated care with other providers, highlighting Kaiser Permanente's commitment to integrated healthcare.
Mentalyc notes provide a comprehensive account of the client's symptoms, functioning, and clinical observations, while adhering to UnitedHealth's guidelines for documentation. Our notes include a well-documented assessment and treatment plan section that outlines the goals and ongoing care plans as required by UnitedHealth. Additionally, we specify the interventions implemented, along with the rationale behind them, and document the client's response to treatment, ensuring compliance with UnitedHealth's standards for evidence-based care. Furthermore, our notes cover thorough risk assessments and address safety concerns, aligning with UnitedHealth's criteria for evaluating and effectively managing potential risks.
Does it work for EMDR therapy?
It does. Many EMDR therapists prefer to take standard progress notes but for those who want to stick to the special EMDR format we have prepared a dedicated note. By subscribing to the Mentalyc PRO plan you unlock your access to this feature on the Mentalyc tool. To learn more about the notes we offer, via this link.
What note formats can I expect?
Our Extended Progress Notes consist of 8 concise sections: Client Presentation (presented problem, symptoms, onset, frequency, etc), Therapeutic Interventions (5 most important ones to keep the note concise), Progress Statement (what the client is getting better at, and what still requires improvement), Client Response (how is the client response to interventions), Goals (what the therapist and client plan to achieve), Plan (what the next steps the client and therapist plan to take, Risk (the chances of the client self-harming or committing suicide) and Homework (The tasks given to the client by the therapist to do at home). The format is dictated by payer requirements and follows best practices. You can easily adjust it to your needs as the note draft is fully editable as any text file (you can format and structure the text in any way). Apart from basic progress notes we also offer Couples therapy notes and EMDR notes. Learn more about our notes.
Who we serve