H2019 Demo (Synthetic Data Only)

Questionnaire → deterministic note output. Do not enter PHI.

Questionnaire

Client Name*

DOB (Demo only)*

Date of Service*

Start Time (24h)*

End Time (24h)*

Modality*

Place of Service*

Target Areas*

Anxiety managementCoping skillsEmotional regulationSocial skillsADLs

Interventions Provided*

Skills trainingPsychoeducationCBTBehavioral coachingDe-escalation

Symptoms Addressed*

Excessive worryRestlessnessIrritabilityImpulsivity

Functional Impact*

Work performanceSchool performanceHome functioningRelationships

Client Response*

Evidence of Response*

Participated in skill practiceVerbalized insightDemonstrated skill use

Suicidal ideation*

Homicidal ideation*

Plan / Next Steps*

Continue skills practice dailyReview coping plan next sessionCoordinate with care team as needed

Provider Name*

Click “Generate Note” to see output here.