Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.
Data:
50-minute office session. Client appeared slightly distracted, glancing around during the initial discussion about work stress and project deadlines. Midway through the session, client expressed anxiety about privacy, asking, "I just need to know, are we being recorded right now? Is anyone else hearing this?" Client reported worrying about this for weeks but not knowing how to bring it up. Therapist reassured client about confidentiality and explained that no recordings or AI tools are used, and notes are taken by hand after sessions. Client appeared relieved and stated they needed to trust the privacy of the space. Discussion returned to work stress, with client appearing more present afterward.
Assessment:
Client demonstrated anxiety related to privacy concerns but responded positively to reassurance and validation. Client's ability to engage in the session improved after addressing these concerns. Progress aligns with building trust and creating a safe therapeutic space, which supports treatment goals.
Plan:
Next session scheduled for the same time next week in the office. Continued focus on addressing work stress and maintaining a safe, trusting therapeutic environment.
We had a 50-minute office session today. Chris came in and we started talking about how work's been going, some stress around a project deadline, pretty normal stuff. He seemed a little distracted though, kept kind of glancing around. About halfway through he asked if he could ask something about how this all works, and I said of course.
He told me that some of his friends have been in therapy and mentioned their therapists record sessions or use AI tools to take notes, and it's been making him anxious. He said quote 'I just need to know, are we being recorded right now? Is anyone else hearing this?' unquote. I could tell it was really bothering him. I reassured him that no, our sessions are completely private, nothing is recorded, I don't use any AI tools or recording devices during our time together. I explained that I take notes by hand after sessions, just the key points I need to remember, and those are kept confidential in his file. I told him that's a personal commitment I've made in my practice, to keep the therapy space as private and human as possible.
He looked so relieved. He said he'd been worrying about it for a couple weeks but didn't know how to bring it up. We talked about how it's totally reasonable to ask questions about privacy and how the process works, and that he should always feel comfortable doing that. He said he just needed to know he could trust that this space is really just between us. I validated that and told him he can ask me about any of this stuff anytime.
After that we got back to talking about the work stress, and he seemed a lot more present. Sometimes these process questions are just as important as the content. We wrapped up and scheduled for next week, same time.
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