Notes
MSE
Clinical Notes
Office
Clinical Skills
100

Completed after a typical session

Counseling FollowUp 

100
What the client tells you

Mood

100

A client denies having suicidality, how would you document this 

“Student denied SI.”

100

833-646-1526 is the number for?

U-Will 

100

The client is giving you some fire quotes in session, what should you do with this.

document them :) 

200

Completed after first initial session with a client

Brief 

200

What you observe 

Affect 
200

Here at the counseling center we don't provide diagnosis, instead we use

Presenting Concerns 

200

CCAPS are completed every _______ session

4th! 

200

changes in emotions, thinking, and behavior that signal a possible mental health condition

Symptoms!

300

Completed after completing treatment with a client 

Termination 

300

What the client does 

Behavior 

300

What is the purpose of a clinical impression?

Hypothesis, Summary, Treatment Plan 

300

A client would like us to talk to their psychiatrist, what do we need first?

an ROI! 

300

A client says they are coming here just to "talk" 


How can you make this a treatment goal? 

good answer!!!

400
Completed after talking over a case with a supervisor and they provide recommendation's 

Supervisor Consult 

400

How the client thinks 

Thought Process 

400

What does "SMART" in SMART GOALS stand for? 

Specific 

Measurable

Attainable

Relevant 

Time-Bound 

400

How would you know when a client is ready for a session on medicat 

It makes a sound, the color changes 

400

When asking a client what brings them to treatment they say "I'm depressed" 


What can be your follow-up to this? 

good answer!!!!! 

500

When talking about a case with someone (ROI provided) 

Consult Note 

500

What the client thinks about 

Thought Content 

500

Affirmed, Assessed, Deesclated, Provided Feedback, Reframed, Utilized, Taught, Identified....

These are 

Intervention Terminology 

500

A client just emailed you, you should document this in a 

contact note!!!! 

500

A client says then want to work on their anxiety


how can you make this into a SMART goal?

Good answer yo!