Clinical Note Builder

Astra Mode

Astra workflow active: individual screeners for intake and a unified Astra GPT route.

Astra Follow-Up

A focused, copy-first documentation workspace designed around your actual visit flow.

Show Intake Script Workspace

Astra note flow

Astra uses one GPT for both intake and follow-up workflows.

Documentation emphasis

Use structured intake screeners for Astra intakes and prior-plan follow-up context for Astra follow-ups.

Workflow Completion

Encounter Progress

0 / 3 complete

Visit Setup Incomplete

Age, gender, start timing, modality, and chief complaint.

Clinical Content Incomplete

Previous plan or intake data plus your freeform appointment notes.

Closing & Follow-Up Incomplete

End times, follow-up modality, and the next appointment details.

Visit Setup

Capture the opening details in the same order you actually work so the export stays stable, complete, and fast.

Core intake details

Age *

Gender *

Scheduled Start *

Current Encounter Modality *

Face-to-Face Start *

Chief Complaint *

The export will place the chief complaint in quotation marks automatically.

Previous Plan / Prior Context

Shown only for follow-ups so the prior roadmap stays exactly where the GPT expects it.

Follow-up context

Previous Plan *

Astra Screeners

Shown for Astra intake only. Astra follow-ups should not display the screener card.

Astra only

PHQ-9

GAD-7

ASRS Part A

ASRS Part B

PCL-5

MDQ

Other

EBH Test / Screener Import

For EBH intake, paste the generated EHR screener block exactly as it appears.

EBH only

Tests / Screeners Dump

Appointment Notes

Write stream-of-consciousness notes in any order. New lines or blank lines are enough for the GPT to separate ideas.

Live note capture

Freeform Notes *

No special symbols are needed between thoughts. Plain line breaks work well.

Intake Script Workspace

Visible only during intake workflows. Keep this open beside the notes box so you can reference the exact questions while typing freely.

Interview prompts

Script sections 0 / 8 complete

Astra intake script loaded. Verbatim prompts below mirror the current uploaded intake script.

Opening & Telehealth Check-In

"Hi, it’s good to meet you. Before we begin, could you confirm your full name and which state you’re in today?"

"Are you in a private place and comfortable doing this visit via telehealth? Everything we discuss is confidential unless there’s an immediate safety concern. Please let me know if anything feels too sensitive—we can pause or come back to it."

Why You’re Here

"What led you to schedule this appointment? What’s been most on your mind?"

"Is there anything else you’d like to make sure we cover today?"

"What are you hoping to get out of our work together?"

Current Symptoms & Impact

"When did you first notice these issues? How have they changed over time?"

"Can you tell me about your mood lately? And how does anxiety show up for you—do you feel it in your body (like tension, racing heart, nausea) or more as persistent worry and rumination?"

"How often do these feelings or symptoms show up, and how intense do they get?"

"What’s the impact on your day-to-day life—work or school, relationships, hobbies?"

"Do certain situations, thoughts, or activities seem to trigger or ease these symptoms?"

"Have you ever experienced periods where you felt unusually energetic or irritable, slept very little but still felt wired, found yourself talking more or taking risks you normally wouldn’t?"

"Have you ever noticed or sensed things others didn’t see or hear, or felt unusually suspicious or paranoid?"

Patterns, Thoughts & Coping

"When you’re feeling anxious or down, what thoughts tend to go through your mind? Do you notice any repetitive patterns or ‘loops’?"

"How do you usually respond in those moments? Are there things you do that help, or habits that seem to make things worse?"

"What strategies have you tried so far—breathing exercises, journaling, physical activity, talking to someone—and how have they worked for you?"

Sleep, Appetite & Physical Symptoms

"Walk me through your sleep routine—when do you go to bed and wake up? How many hours of sleep are you getting, and do you wake up during the night?"

"Any nightmares or particularly vivid dreams?"

"What about your appetite—any significant changes in how much or how often you eat?"

"Have you had physical symptoms that seem connected to your mood—like headaches, stomach issues, muscle tension, or anything else?"

Immediate Safety & Risk

"Have you ever intentionally hurt yourself or another person?"

"Right now, are you thinking about harming yourself or anyone else? Do you have a specific plan or access to means?"

"Are there situations, thoughts, or feelings that tend to trigger these thoughts?"

"Do substances or other factors make those thoughts stronger?"

"What keeps you going when things feel really hard? Who or what are your reasons for staying safe?"

"If things got worse, who could you turn to—friends, family, or professionals?"

Past Mental Health & Treatments

"Have you ever been diagnosed with a mental health condition?"

"Have you been hospitalized or participated in programs like residential treatment, partial hospitalization, or intensive outpatient?"

"What kinds of therapy have you tried (CBT, DBT, EMDR, or others)? What was helpful or not?"

"Let’s go over any psychiatric medications you’ve taken in the past: names, doses, how long you took them, whether they helped, and why they were stopped. This helps if we ever need to request a prior authorization."

"Have you ever stopped a medication on your own? What was going on at the time?"

"Any past suicide attempts or self-harm behaviors?"

Current Medications & Medical History

"Do you have any allergies to medications, foods, or other substances?"

"Please list the medications you’re currently taking—both for mental health and physical health—including doses and how often you take them."

"Are you taking any vitamins, herbal supplements, or over-the-counter products? What are the doses?"

"Do you take your medications consistently?"

"Do you have any chronic health conditions—like diabetes, thyroid issues, high blood pressure, heart disease, chronic pain, or autoimmune disorders?"

"Any history of seizures, concussions, head injuries, or neurological issues?"

"Any breathing problems like asthma, COPD, or sleep apnea?"

"Have you had any surgeries? If yes, what kind and when?"

"Could you share your height and weight?"

"Is there any chance you’re pregnant or trying to become pregnant?"

Substance Use

"I ask everyone about substance use because it can impact treatment. Do you drink alcohol? If so, how much and how often?"

"Do you use cannabis or THC products? How often?"

"Do you use nicotine or caffeine? How much?"

"Do you use any other substances, including prescription meds not prescribed to you, stimulants, opioids, or other drugs?"

"When was the last time you used any of these?"

"Do you have any concerns about your substance use?"

Family Mental Health History

"Do any family members have mental health conditions—depression, anxiety, bipolar disorder, psychosis, or substance use disorders?"

"Is there any history of suicide or suicide attempts in your family?"

Social & Life Context

"Where did you grow up, and have you lived elsewhere?"

"What’s your current living situation?"

"Are you working, in school, looking for work, retired, or on disability? How do you feel about your current role?"

"Who are the people you can count on for support?"

"Have you been facing any major stressors recently—financial issues, housing problems, relationship difficulties, caregiving responsibilities, or health concerns?"

"Have you ever had legal issues?"

"Have you experienced traumatic events earlier in life or more recently that still affect you?"

"Do you have access to firearms?"

Daily Functioning & Coping

"How are you managing daily tasks like cooking, cleaning, paying bills, and running errands?"

"Any challenges with personal care—bathing, dressing, or grooming?"

"What do you enjoy doing in your free time? How often do you get to do those things?"

"What coping strategies work best for you when you’re feeling anxious, depressed, or stressed?"

Goals, Motivation & Strengths

"Looking ahead, what changes would you like to see in your life?"

"On a scale from 1 to 10, how important is it for you to make those changes? What makes it that number and not lower? What might help you move closer to 10?"

"What personal strengths, values, or resources could help you succeed?"

"What challenges or barriers do you anticipate, and how might we address them together?"

Wrap-Up

"We’ve covered a lot. Is there anything I haven’t asked that feels important to mention?"

"Do you have any questions about what we discussed or what happens next?"

"Would you like to talk about creating or updating a safety plan together?"

Closing / Follow-Up

Finish the visit, choose the next interval if needed, and keep follow-up scheduling in the export.

Scheduling + close

Face-to-Face End *

Documentation End *

Follow-Up Modality *

Quick Follow-Up Interval

Selecting an interval should auto-fill the follow-up date while still allowing manual edits.

Follow-Up Date *

Follow-Up Time *

Export

Preview the structured raw input live, then copy it into the appropriate GPT.

Final handoff

The correct GPT can be opened automatically based on the selected practice and appointment type.

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