Notes

Clinical Documentation Suite

👤 Client Information

Full Name

Date of Birth

Gender

Marital Status

Referral Source

Phone

Emergency Contact

📋 Presenting Problems

Select all that apply

Duration

Severity

Onset

🧠 DSM-5 Symptom Criteria Checklist

Check all symptoms the client endorses. The system evaluates against DSM-5 diagnostic criteria and shows which diagnoses meet threshold.

📊 Mental Status Exam

⚠️ Risk Assessment

🏠 Psychosocial History

Current Medications

🎙 Clinical Impressions

Step 1: Dictate or type your raw impressions in your own words.

AI rewrites your notes professionally

✨ AI Clinical Decision Support

Generate diagnostic and treatment suggestions based on intake data.

🏥 Diagnosis

Primary Diagnosis

Secondary Diagnosis

🎯 Treatment Goals

💊 Interventions

Select planned interventions

Session Frequency

Estimated Duration

📝 Additional Notes

📅 Session Information

Session Date

Session #

Client Mood

🎙 D — Data (Session Summary)

Dictate or type the session summary.

📊 A — Assessment

Progress Status

Current Risk

Interventions Used

📋 P — Plan

Plan for Next Session

Homework