Free Case Consultation Note Template

What is a case consultation note?

A case consultation note documents an interdisciplinary discussion about a complex or challenging client case. Case consultations bring together clinicians from different disciplines or settings to provide diverse perspectives on diagnosis, formulation, and treatment planning. A psychiatrist, therapist, and social worker might consult together on a client with comorbid substance use and trauma. A school counselor might consult with an outside psychologist about a child with severe anxiety. Multiple therapists in a group practice might gather to discuss treatment approaches for a client with complex needs. These consultations improve clinical care by leveraging collective expertise, reduce clinical isolation, generate creative problem-solving, and distribute the responsibility for complex cases. Consultation notes create a record of who participated, what was presented, what perspectives were offered, and what recommendations the team endorsed. These notes are part of the client's clinical record and inform ongoing treatment coordination.

What's in this template

This case consultation note template includes:

• Consultation Information: Date, time, location (or virtual platform), consulting disciplines/roles present, primary clinician requesting consultation
• Client Identifying Information: Client name/initials, relevant demographics (age, diagnosis), presenting problems, reason for consultation
• Case Presentation: The primary clinician's summary of the client's history, current clinical status, treatment to date, what has worked and what has not, what is currently unclear or stuck
• Relevant Clinical Data: Recent assessment results, psychiatric or medical diagnoses, current medications, risk assessments, previous evaluations or records from other providers
• Specific Questions for Consultation: What is the primary clinician asking the consultants to address? Diagnostic questions? Treatment approach options? Risk assessment? Coordination with other providers?
• Consultant Perspectives: Each participating clinician's observations, diagnostic impressions, clinical reasoning, and recommendations based on their discipline and expertise
• Discussion Summary: Themes that emerged in discussion, areas of agreement, areas of respectful disagreement, new insights or reframes generated by the group
• Clinical Recommendations: Specific recommendations endorsed by the consultation group (treatment modifications, diagnostic clarification, referrals, additional evaluations, medication adjustments, care coordination steps)
• Risk Assessment & Safety Planning: Any safety concerns identified, risk mitigation strategies, responsibility for follow-up on urgent concerns
• Coordination & Communication Plan: How recommendations will be communicated to the client, other providers, and the treatment team; timeline for follow-up
• Next Steps & Follow-up: When to reconvene if needed, how to communicate progress on recommendations, documentation of action items
• Consultant Signatures & Credentials: Each participant documents their name, credentials, discipline, and signature for accountability

When to use this template

Use the case consultation note when:

• Multiple disciplines meet to discuss a complex or challenging case
• A client's treatment is stuck or progressing slower than expected
• There is diagnostic uncertainty requiring diverse clinical perspectives
• Risk assessment or safety planning requires multidisciplinary input
• Coordination between providers needs to be documented and formalized
• A case requires perspectives beyond a single clinician's expertise or discipline
• Responding to client or family requests for a "second opinion" or expert perspective

This template is used across all healthcare settings: psychiatric hospitals, outpatient clinics, group practices, schools, community mental health centers, and integrated primary care clinics.

How to use the template with Scriber

Record your case consultation meeting with consent and Scriber transcribes the full discussion. Rather than trying to capture the case presentation, consultant perspectives, and recommendations in real time while also actively participating, you have a complete transcript. Use the transcript to organize the consultation into the note template: extract the case presentation, each consultant's perspective and recommendations, the group's discussion and decision-making, and action items agreed upon. Add your clinical observations, confirm diagnoses or clinical reasoning not fully captured in transcription, and ensure the note accurately reflects the team's recommendations. This approach keeps all consultants engaged in the discussion while AI handles transcription.

Download (free)

This template is available as a printable PDF and editable DOCX file. Customize it to match your consultation practice, adjust for your specific disciplines and settings, and use it as a standard form for all case consultations.

[Download PDF]

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