This is the In-Session Note that I use to guide myself during a clinical assessment. It helps me cover all the bases, reminds me of what I've forgotten to evaluate/inquire about, and prepares me for my write up. The abbreviations are relatively standard within the field of psychology and medicine.
This is an Outline of an Intake Narrative. It is very comprehensive and a bit redundant, but it ensures a well thought out write-up.
The product of the above outline is this Detailed Model Intake Narrative. This narrative is very long and detailed, which is probably not necessary. Instead, the same note can easily be shortened to become an abbreviated Model Intake Narrative. These examples are purely fictitious and are not meant to resemble any individual or composite of individuals.
This is an example of the first counselor's paper from my Advanced Techniques in Counseling class. This is a good example of a well-written paper, though there is plenty of room for variation from author to author.
For more information about these materials contact Michael Heitt, PsyD.