Date: SESSION_DATE Patient: PATIENT_NAME Provider: DOCTOR_NAME Diagnosis: [Patient's Diagnosis, if applicable] Presenting Problem: PATIENT_NAME presented with concerns about [Presenting Problem, if applicable]. Mental Status: PATIENT_NAME appeared alert and oriented. Mood was reported as [Mood, if applicable], but affect was congruent with mood. Speech was clear and coherent. Thought process was logical and goal-directed. No evidence of psychosis or suicidal ideation. History of Present Illness: [History of Present Illness, if applicable] Past Psychiatric History: [Patient's Past Psychiatric History, if applicable] Medical History: [Patient's Medical History, if applicable] Social History: [Patient's Social History, if applicable] Family History: [Patient's Family History, if applicable] Medications: [Patient's Current Medications, if applicable] Treatment Plan: • [Specific treatment plans discussed during the session, if applicable] Goals: • [Specific goals discussed during the session, if applicable] Prognosis: Prognosis is good with continued therapy and adherence to treatment plan. Next Steps: • [Next steps discussed during the session, if applicable] Notes: • [Additional notes from the session, if applicable]