Telehealth Session Note Template

What’s Included

This Telehealth Session Note Template is designed to capture comprehensive clinical information during virtual mental health appointments. It includes structured sections for Identifying Information, Presenting Problem, Mental Status Examination, Clinical Impressions, and Treatment Plan. Each section features clearly labeled fields such as patient demographics, session date/time, modality (video, phone), subjective report, objective observations, assessment, and plan, ensuring thorough documentation that meets clinical and legal standards.

Additional components include prompts for risk assessment (suicidality, homicidality), medication updates, patient goals, and follow-up scheduling. The template also provides space for clinician reflections and notes on technical or environmental factors affecting the telehealth session. This organization supports accurate, consistent, and efficient note-taking tailored specifically for remote mental health care.

Who This Template Is For

This template is ideal for mental health clinicians conducting telehealth sessions, including psychologists, psychiatrists, licensed clinical social workers (LCSWs), licensed professional counselors (LPCs), marriage and family therapists (MFTs), psychiatric nurse practitioners, and other behavioral health providers who require detailed and compliant documentation of virtual patient encounters.

How to Use

Begin by entering patient identifying information and the session details at the top of the note. Use the Presenting Problem section to summarize the patient’s chief complaints or concerns as discussed during the telehealth visit. Complete the Mental Status Examination with observations noted through the video or phone interaction, paying special attention to mood, affect, thought processes, and behavior.

Document your clinical impressions based on the session content and your professional assessment, followed by a clear treatment plan that outlines interventions, therapy goals, medication changes (if applicable), and any referrals or follow-up plans. Be sure to include any risk assessments conducted during the session. Review the note for clarity and completeness before finalizing to ensure it accurately reflects the encounter.

Customize with MentalNote

Using MentalNote AI, you can effortlessly generate fully formatted telehealth session notes directly within Microsoft Word. Simply input key clinical details or upload brief session summaries, and MentalNote will create a professional, structured document tailored to your specialty’s requirements. This automation streamlines your workflow, reduces administrative burden, and helps maintain consistent, high-quality clinical documentation for every telehealth encounter.