Documentation that sees the whole person and still meets the standard.
The Seen and Known clinical documentation collection follows a client from first contact through closing. It was built by a clinician for outpatient therapists who want notes that honor the work, support medical necessity, and take less time to write.
Every form is integrative and trauma-informed, written in clear clinical language, and organized so that what you mark during session moves straight into your official note.
WHAT'S INCLUDED (20 files)
Intake
- Clinical Intake Interview: a 60-minute biopsychosocial and diagnostic assessment with timed sections and prompts
- Couples and Family Intake: conjoint interviewing with private safety check-ins and EFT cycle mapping
- Assessment Bundle: MHC-SF, PHQ-9, GAD-7, CAGE-AID, LEC-5, and ACE in a trauma-informed order, with scoring guidance and a summary sheet
- Couples and Family Consent: no-secrets and limited-secrets policy options
- Telehealth Emergency Plan
Treatment planning
- Client-facing treatment plan with measurable, numbered objectives
- Client self-review worksheet
- 180-day treatment plan review
Every session
- Individual and conjoint in-session note sheets, designed for tablets and handwriting
- Clinical documentation templates: progress notes for individual, couples, and family sessions; 50-entry intervention language bank; safety documentation statements; diagnosis justification for 25+ diagnoses; relational codes and billing guidance
- Measurement tracker (Excel) with severity flags, change from intake, and automatic trend charts
Safety and risk
- Suicide risk assessment with clinical formulation
- Client safety plan with pocket card
Between sessions
- Contact notes for calls, collateral contacts, coordination, crisis contacts, and missed appointment outreach
- Coordination of care letter
- Supervision notes with licensure hours tracking
Closing
- Discharge summary
- Closing letters for ending together and for clients who stop attending
Plus a collection index showing which file to use at each stage of care.
APPROACHES REPRESENTED
Compassionate Inquiry, Gestalt, person-centered, trauma-informed, somatic, parts and schema work, EFT, DBT adaptations for high-conflict couples and families, ACT, CBT, SFBT, structural and Bowen family therapy, and intersectional practice.
WHO IT'S FOR
Licensed and pre-licensed counselors, therapists, social workers, and psychologists in outpatient practice, group practice, or agency settings.
FILE DETAILS
- Word documents you can edit, plus PDFs ready to print or use on a tablet
- One Excel workbook
- Instant download; nothing is shipped
- Delivered as zip files. Unzip on a computer before opening.
PLEASE NOTE
- Built for Minnesota practice. Minnesota-specific sections, such as the diagnostic assessment crosswalk, are clearly labeled and can be removed or adapted to your state.
- These templates support, but do not replace, clinical judgment, supervision, or legal consultation. Verify requirements with your state board, payers, and agency.
- Assessment measures are reproduced under their developers' free-use terms, with full credit. The BASIS-24 is a licensed instrument and is not included.
LICENSE
Purchase grants one clinician the right to use and adapt these files in their own practice. Please do not resell, share, or redistribute the files. For a group practice license, send me a message.
Because this is a digital product, all sales are final. If anything doesn't open correctly, message me and I'll make it right.
Seen and Known: Healing on a Continuum
Documentation that sees the whole person and still meets the standard.
The Seen and Known clinical documentation collection follows a client from first contact through closing. It was built by a clinician for outpatient therapists who want notes that honor the work, support medical necessity, and take less time to write.
Every form is integrative and trauma-informed, written in clear clinical language, and organized so that what you mark during session moves straight into your official note.
WHAT'S INCLUDED (20 files)
Intake
- Clinical Intake Interview: a 60-minute biopsychosocial and diagnostic assessment with timed sections and prompts
- Couples and Family Intake: conjoint interviewing with private safety check-ins and EFT cycle mapping
- Assessment Bundle: MHC-SF, PHQ-9, GAD-7, CAGE-AID, LEC-5, and ACE in a trauma-informed order, with scoring guidance and a summary sheet
- Couples and Family Consent: no-secrets and limited-secrets policy options
- Telehealth Emergency Plan
Treatment planning
- Client-facing treatment plan with measurable, numbered objectives
- Client self-review worksheet
- 180-day treatment plan review
Every session
- Individual and conjoint in-session note sheets, designed for tablets and handwriting
- Clinical documentation templates: progress notes for individual, couples, and family sessions; 50-entry intervention language bank; safety documentation statements; diagnosis justification for 25+ diagnoses; relational codes and billing guidance
- Measurement tracker (Excel) with severity flags, change from intake, and automatic trend charts
Safety and risk
- Suicide risk assessment with clinical formulation
- Client safety plan with pocket card
Between sessions
- Contact notes for calls, collateral contacts, coordination, crisis contacts, and missed appointment outreach
- Coordination of care letter
- Supervision notes with licensure hours tracking
Closing
- Discharge summary
- Closing letters for ending together and for clients who stop attending
Plus a collection index showing which file to use at each stage of care.
APPROACHES REPRESENTED
Compassionate Inquiry, Gestalt, person-centered, trauma-informed, somatic, parts and schema work, EFT, DBT adaptations for high-conflict couples and families, ACT, CBT, SFBT, structural and Bowen family therapy, and intersectional practice.
WHO IT'S FOR
Licensed and pre-licensed counselors, therapists, social workers, and psychologists in outpatient practice, group practice, or agency settings.
FILE DETAILS
- Word documents you can edit, plus PDFs ready to print or use on a tablet
- One Excel workbook
- Instant download; nothing is shipped
- Delivered as zip files. Unzip on a computer before opening.
PLEASE NOTE
- Built for Minnesota practice. Minnesota-specific sections, such as the diagnostic assessment crosswalk, are clearly labeled and can be removed or adapted to your state.
- These templates support, but do not replace, clinical judgment, supervision, or legal consultation. Verify requirements with your state board, payers, and agency.
- Assessment measures are reproduced under their developers' free-use terms, with full credit. The BASIS-24 is a licensed instrument and is not included.
LICENSE
Purchase grants one clinician the right to use and adapt these files in their own practice. Please do not resell, share, or redistribute the files. For a group practice license, send me a message.
Because this is a digital product, all sales are final. If anything doesn't open correctly, message me and I'll make it right.
Seen and Known: Healing on a Continuum
