No-Show/Late Cancellation Note (Behavioral Health)

Appointment Details

Date/Time of Scheduled Appointment: [Scheduled appointment date and time]
Patient: [Patient name or identifier]
Clinician: [Clinician name and credentials]
Modality: [in-person / video / phone / group]
Visit Type: [psychotherapy / medication management / intake / other]

Attendance & Reason

[Attendance status: no-show / late cancellation / technical failure]. [Reason for missed appointment, attributed to source] (Include reason only if explicitly provided by patient, family, or system—e.g., "Patient stated..."; otherwise state "Reason not provided" or omit per workflow. Note clinic grace period only if applicable.) Patient not present; no clinical services provided.

Outreach Log

(If no outreach was performed, replace with "No outreach indicated" or omit section entirely.)

• [Date/time] — [Method: call / text / portal message / letter] — [Outcome: no answer / voicemail left / message delivered / spoke with patient] — [Next step] (Do not include full phone numbers.)
• (Add additional entries as needed, one line per attempt.)

Risk/Safety Follow-Up

(Include this section ONLY when clinically indicated—e.g., documented recent suicidal ideation, active safety plan, recent psychiatric hospitalization, or per program policy for specific risk tiers. Otherwise, omit this section entirely.)

• Trigger for follow-up: [Specific clinical indicator prompting safety outreach]
• Actions taken: [Additional contact attempts / crisis resources provided / emergency contact notified / supervisor consulted / welfare check initiated] — [Timestamps]
• Outcome: [If reached: patient-reported status and disposition] or [If not reached: "Risk not reassessed due to inability to contact; plan for continued follow-up: [specify]"]
• Reference: [Last documented risk level with date] (Clearly historical; do not upgrade or downgrade based solely on missed attendance.)

Plan

• Rescheduling: [New appointment date/time scheduled] or [Instructions provided for patient to reschedule]
• Care coordination: [Treating clinician notified / supervisor consulted / pattern communicated] (Include only if applicable.)
• Administrative disposition: [Non-billable event / missed-appointment fee assessed / fee waived] (Include only if required by workflow.)
• (If any separately billable clinical contact occurred during outreach, note that documentation exists in a separate clinical note.)

Signature: [Name, credentials, role]
Date/Time Signed: [Date and time note signed]