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Mental health consult note template

Australian documentation guide

Bring the person's story, your assessment and the agreed next steps into one clear note. Use it for a mental health consultation, keeping the current findings, wider history and any unfinished assessment easy to follow.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

A useful mental health note tells the person’s story and makes the next steps easy to follow. This template brings the conversation, assessment and agreed plan together. For help describing individual examination findings, see the mental state assessment guide.

A consult note and a Medicare Mental Health Treatment Plan are separate documents. If you performed that service, check the current MBS requirements as well.

Reason for visit

Start with why the person came and what they hope to get from the visit. Note whether it was an initial assessment, review, medicine discussion or request for a referral. Include how you met and who supplied the information.

A phrase such as “wants help with worry affecting work” gives the next reader more context than “mental health review”. Note interpreter use, another person’s account or a brief contact where relevant.

Presenting issue

Use the person’s own account of the concern, its timing and its effect on everyday life. A short quotation can help keep their meaning. Make it clear when information came from a relative or from your observation.

If a screening tool was used, name it and include the result and interpretation actually recorded. A score or symptom description alone does not supply a diagnosis. Keep anything not explored visible.

Past psychiatric history

Include earlier diagnoses, episodes, treatment and responses that were discussed. Say whether this came from the person or from available records. “No previous treatment reported” is more precise than “no psychiatric history” when that is all you know.

Keep relevant physical health, substance use, family and social context where discussed. An earlier episode does not establish the cause of today’s concerns.

Current medications

List the medicines and non-prescription products discussed, with names, directions and current use where known. Identify an old list, a reported stop or a product still needing clarification. Allergy and adverse-reaction information can go here or in the linked record; there is no separate allergy heading.

Use phrases such as “reports taking” or “prescribed today” to show what is known. Leave missing doses, indications and adherence information for clarification.

Mental state examination

Describe the areas assessed and the clinician’s observations. Keep the person’s reported mood separate from observed affect, and thought organisation separate from thought content.

State the limits of a telephone or other remote contact. Appearance needs a visual observation; a fluent conversation does not establish normal cognition or a complete normal MSE. The MSE guide has vocabulary for each domain.

Risk and safety assessment

Set out what was explored, the person’s answers, relevant history and the clinician’s assessment. Include agreed actions. Where discussed, keep thoughts, intent, plans, access to means, previous events and supports distinct.

“Denies current suicidal thoughts when asked” describes one answer. It does not mean the whole assessment is complete. Keep an absent discussion as [not stated], and an incomplete assessment clearly labelled. A risk category or safety plan belongs here only if the clinician stated it.

Assessment

Use the clinician’s stated formulation, diagnosis and level of certainty. Words such as “provisional”, “working formulation” or “further assessment needed” help the next reader understand the limits.

Keep symptoms, previous diagnoses and screening results separate from a new conclusion. If information is still needed, say what remains unclear.

Plan

Make the next steps easy to follow: what was discussed, what was agreed, who will do it and when. Keep a possible referral separate from one issued, and a requested appointment separate from a confirmed booking.

Include consent, information provided and safety advice as discussed. Keep treatment directions exactly as given. This note alone does not show that a separate treatment plan or eligibility check was completed.

Supports

Name the people or services the person identifies and the help actually agreed. Include availability and permission to make contact when discussed.

“Identifies partner as a support” does not establish a care role or consent to share information. “Availability unknown” or “contact not yet agreed” can be useful details.

Common omissions

Before finishing, look for the history’s source, MSE limits, unfinished risk discussion, uncertain medicines and referral status. Check that support arrangements and permission to share information have survived the summary.

Review before saving

Read the note alongside the encounter. Check quotations, explicit negative answers, agreed actions and remaining gaps. Missing risk information must not become “no risk”. The clinician must review and explicitly confirm generated content before saving or sharing it.

Worked examples

Worry and disrupted sleep: a review with assessment still to finish

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR VISIT: Fictional in-person GP review. Person wants to discuss worry and poor sleep affecting their work. They supply the history themselves; no collateral account is obtained.
PRESENTING ISSUE: Person reports six weeks of worry about work deadlines, difficulty getting to sleep and two missed workdays. They describe wanting help with the worry rather than a sleeping-tablet prescription. Other associated symptoms are not recorded in this extract.
PAST PSYCHIATRIC HISTORY: Person reports previous counselling during a stressful period three years ago, with no diagnosis recalled. Previous service records have not been obtained.
CURRENT MEDICATIONS: Person reports no regular prescription medicines and occasional use of an unnamed herbal sleep product. Product ingredients and directions are not yet verified. Person reports no known medicine allergy; this is reported history.
MENTAL STATE EXAMINATION: GP describes coherent, relevant answers and an anxious but reactive affect. Person describes their mood as "wound up". Cognition and perception are not formally assessed; no complete normal MSE is asserted.
RISK & SAFETY ASSESSMENT: Person denies current suicidal thoughts and thoughts of harming others when asked. Previous self-harm, access to means and safeguarding are not yet explored. GP records that the risk assessment is incomplete and does not assign an overall risk category in this extract.
ASSESSMENT: GP records anxiety symptoms with sleep disruption; diagnostic formulation remains provisional. No confirmed diagnosis is recorded.
PLAN: Person agrees to a further assessment appointment. GP will clarify the herbal product and complete the outstanding history and risk discussion. Referral options were discussed but no referral was issued at this visit.
SUPPORTS: Person identifies a partner as a source of support. Permission to contact the partner has not been sought; availability for a care role is not established.

A brief telephone contact with assessment still outstanding

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR VISIT: Fictional telephone contact requesting a follow-up appointment after a change in mood.
PRESENTING ISSUE: Person says they have felt "low" for the past week. Duration beyond this, functional effect and associated symptoms are not explored during the extract.
PAST PSYCHIATRIC HISTORY: [not stated]
CURRENT MEDICATIONS: Person refers to a current prescription but its name and directions are not stated.
MENTAL STATE EXAMINATION: Appearance and the visual aspects of affect cannot be assessed by telephone. Other MSE findings are not stated.
RISK & SAFETY ASSESSMENT: [not stated]
ASSESSMENT: No diagnostic or overall risk assessment is recorded in this extract.
PLAN: A follow-up appointment is requested. Booking status, timing and any interim advice are not stated; this extract needs clinician review.
SUPPORTS: [not stated]

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.