17 REAL Mental Health Progress Note Templates and Examples
Templates
As a mental health professional, writing effective progress notes is a crucial part of providing quality patient care. Psychotherapy progress notes serve as a record of client progress, help track treatment goals, and are often required for insurance reimbursement. However, with various note templates available, it can be challenging to determine which one best suits your needs. This comprehensive guide will explore 18 of the best progress note templates and provide examples to help you streamline your clinical documentation process.
Introduction: Focusing on Medical Necessity in Progress Notes
When writing therapy progress notes, it's essential to focus on demonstrating medical necessity. Medical necessity is the justification that a treatment or service is required for the diagnosis, care, or treatment of a patient's mental health condition. Here are key elements to include in psychotherapy notes:
Symptoms and Behaviors: Document specific symptoms and behaviors that indicate the need for continued treatment.
Functional Impairment: Describe how the client's condition affects their daily functioning, relationships, or work/school performance.
Treatment Goals: Clearly state the goals of treatment and how they relate to the client's diagnosis and functional impairment.
Interventions: Detail the therapeutic interventions used and their rationale.
Client's Response: Document how the client responds to interventions and any progress made towards treatment goals.
Plan: Outline the ongoing treatment plan and any adjustments made based on the client's progress.
By focusing on these elements, you can create progress notes that not only track client progress but also justify the necessity of ongoing treatment to insurance providers.
Using AI to Automate Writing of Progress Notes
Artificial Intelligence (AI) is revolutionizing many aspects of healthcare, including the process of writing progress notes. AI Therapy Note tools can help mental health professionals save time, maintain consistency, and potentially improve the quality of their clinical documentation. They directly listen in to sessions and write SOAP notes or any other notes.
Here's how AI can assist in writing progress notes:
Time saving: AI therapy note tools directly listen into sessions and can write progress notes,
Template Population: AI tools can automatically populate progress note templates with relevant information extracted from the session transcript.
Medical Necessity Highlighting: AI can identify and highlight elements in the notes that demonstrate medical necessity, ensuring comprehensive documentation for insurance purposes.
Consistency Checking: AI can review notes for consistency with previous sessions and treatment plans, flagging any discrepancies for the therapist to review.
Popular AI tools for progress notes include:
Supanote: Secure platform that listens to sessions and writes progress notes. Comes pre-built with several therapy progress note templates like SOAP notes, DAP, GIRP and many more
Therasoft: Integrates AI capabilities into its practice management software for automated note-taking.
18 Best Progress Note Templates
1. SOAP Note Template and Example
The SOAP notes (Subjective, Objective, Assessment, Plan) are one of the most widely format for psychotherapy notes.
Example:
S: Client reports feeling anxious about upcoming job interview, stating "I can't sleep at night thinking about all the ways I could mess up." Reports increased heart rate and sweating when thinking about the interview.
O: Observed client fidgeting throughout the session, speaking rapidly, and avoiding eye contact. Breathing appeared shallow and quick. Client scored 18 on the GAD-7 anxiety scale, indicating moderate to severe anxiety.
A: Generalized Anxiety Disorder, moderate severity. Client's anxiety symptoms are significantly impacting daily functioning, particularly sleep and ability to pursue career opportunities. Current coping mechanisms appear insufficient to manage anxiety levels.
P: 1. Continue weekly CBT sessions focusing on cognitive restructuring of negative thought patterns related to job performance.
2. Introduce and practice progressive muscle relaxation and diaphragmatic breathing exercises in session.
3. Assign homework: Client to practice relaxation exercises daily and log anxiety levels before and after.
4. Consider referral for psychiatric evaluation if anxiety symptoms do not show improvement in next 3 sessions.
2. DAP Note Template and Example
DAP note format (Data, Assessment, Plan)is concise and focuses on key information.
Example:
D: Client discussed recent conflict with spouse over financial issues. Reports feeling "constantly on edge" and having difficulty concentrating at work. States argument escalated to shouting, with client leaving the house to "cool off." Client expressed remorse for reaction and desire to improve communication.
A: Marital discord is significantly affecting client's mood and daily functioning. Client shows insight into own role in conflict but lacks effective communication and emotion regulation skills. Current situation is exacerbating underlying anxiety symptoms.
P: 1. Introduce communication exercises focusing on active listening and "I" statements in next couples therapy session.
2. Teach and practice mindfulness techniques to help client manage emotional reactivity.
3. Assign homework: Client to keep thought journal recording automatic thoughts during conflicts.
4. Schedule individual session with spouse to assess their perspective and willingness to engage in couples therapy.
3. BIRP Note Template and Example
BIRP notes (Behavior, Intervention, Response, Plan) are particularly useful for tracking specific behaviors and interventions.
Here's a short sample BIRP note:
B: Client exhibited signs of social withdrawal.
I: Introduced gradual exposure techniques.
R: Client expressed willingness to try small social interactions.
P: Develop hierarchy of social situations for exposure therapy.
4. GIRP Note Template and Example
GIRP (Goal, Intervention, Response, Plan) notes focus on treatment goals and client responses.
Example:
G: Reduce depressive symptoms by 50% within 3 months.
I: Implemented behavioral activation strategies.
R: Client reported slight mood improvement after engaging in pleasurable activities.
P: Continue behavioral activation, introduce cognitive restructuring techniques.
5. PIRP Note Template and Example
PIRP (Problem, Intervention, Response, Plan) notes emphasize problem-solving approaches
Example:
P: Client struggling with panic attacks in public spaces.
I: Taught diaphragmatic breathing and grounding techniques.
R: Client successfully used techniques to manage a mild panic attack.
P: Practice techniques in progressively challenging environments.
6. SBAR Note Template and Example
SBAR (Situation, Background, Assessment, Recommendation) notes are useful for concise communication among healthcare professionals and not just for psychotherapy notes
Example:
S: Client experiencing acute suicidal ideation.
B: History of major depressive disorder, recent job loss.
A: High risk for self-harm, requires immediate intervention.
R: Recommend inpatient psychiatric evaluation and 24-hour supervision.
7. CBT Note Template and Example
CBT (Cognitive Behavioral Therapy) notes focus on the relationship between thoughts, feelings, and behaviors.
Here's a much longer example of a real-life CBT progress notes:
Client: Jane Doe
Date: MM/DD/YYYY
Session #: 8
Presenting Issue: Continued social anxiety in workplace settings
Cognitive Distortions Identified:
1. Mind reading: "Everyone at work thinks I'm incompetent"
2. Catastrophizing: "If I make a mistake in the meeting, I'll get fired"
Behavioral Patterns:
- Avoiding team meetings when possible
- Over-preparing for presentations, leading to sleep deprivation
Emotions:
- Anxiety (rated 8/10) when thinking about work interactions
- Frustration (rated 7/10) with self for not overcoming anxiety
Interventions:
1. Cognitive restructuring: Challenged thought "Everyone thinks I'm incompetent"
- Evidence for: Made mistake in last presentation
- Evidence against: Received positive feedback on recent project, coworkers often ask for help
2. Behavioral experiment: Attended team meeting without over-preparing, rated anxiety before and after
Client's Response:
- Successfully identified and challenged negative automatic thoughts
- Reported decrease in anxiety (6/10) after behavioral experiment
Homework:
1. Continue thought record, focusing on work-related situations
2. Practice progressive muscle relaxation daily before work
3. Engage in one social interaction at work without over-preparing
Plan for Next Session:
- Review thought record and discuss any challenges
- Introduce exposure hierarchy for work-related anxiety-provoking situations
- Continue cognitive restructuring with focus on perfectionism
Progress Towards Treatment Goals:
Client showing improvement in ability to identify and challenge cognitive distortions. Behavioral experiments are helping to build confidence in social situations. Continue to work on generalizing skills to various workplace scenarios.
8. Narrative Progress Note Template and Example
Narrative notes allow for a more detailed, story-like account of the therapy session. They can be short or long
Example:
Today's session focused on exploring the client's relationship with their mother. The client expressed feelings of resentment and unresolved childhood issues. We discussed strategies for setting healthy boundaries and practiced assertive communication techniques. The client showed insights into their behavior patterns and agreed to journal about their feelings between sessions.
9. Bullet Point Progress Note Template and Example
Bullet point notes offer a quick, easy-to-read format for documenting key points. They're typically 5-10 points
Example:
- Client reported improved sleep patterns
- Discussed progress on anger management techniques
- Introduced mindfulness exercises
- Assigned homework: Practice deep breathing 2x daily
- Next session: Review mindfulness practice and continue anger management work
10. Timeline Progress Note Template and Example
Timeline notes are helpful for tracking events or symptoms over time.
Example:
Week 1: Client began medication for depression
Week 3: Reported 30% reduction in depressive symptoms
Week 5: Experienced side effect of increased appetite
Week 6: Adjusted medication dosage
Week 8: Side effects subsided, continued improvement in mood
11. Crisis Intervention Note Template and Example
Crisis notes focus on immediate concerns and actions taken during a crisis situation.
Example:
Crisis Situation: Client called reporting suicidal thoughts
Risk Assessment: Medium risk - has plan but no immediate intent
Intervention: Conducted safety planning, provided crisis hotline information
Follow-up: Scheduled urgent appointment for tomorrow, alerted on-call psychiatrist
12. Group Therapy Note Template and Example
Group therapy notes capture the dynamics and progress of multiple clients in a group setting.
Example:
Group Topic: Coping with Anxiety
Participants: 6 attendees (list initials)
Group Dynamics: Supportive atmosphere, active participation
Individual Notes:
- J.D.: Shared fear of public speaking, received peer support
- M.S.: Practiced deep breathing technique, reported feeling calmer
- L.T.: Remained quiet, encouraged to share next session
Plan: Continue anxiety management techniques, introduce cognitive restructuring next week
13. Couples Therapy Note Template and Example
Couples therapy notes focus on relationship dynamics and interventions.
Example:
Couple: John and Jane Doe
Presenting Issue: Communication breakdown
Observations: John tends to withdraw, Jane becomes critical
Intervention: Introduced active listening exercises
Response: Both partners engaged willingly, reported feeling heard
Plan: Continue communication skills training, explore attachment styles next session
14. Child Therapy Note Template and Example
Child therapy notes often include play-based interventions and developmental considerations.
Example:
Client: Tommy, age 7
Presenting Issue: Separation anxiety
Session Activity: Sand tray therapy
Observations: Created scene with family members close together, expressed fear of school
Intervention: Introduced coping strategies through storytelling
Plan: Involve parents in next session, continue building self-soothing skills
15. Integrated Progress Note Template and Example
Integrated notes combine elements from multiple templates for a comprehensive view.
Example:
Client: John Smith
Date: MM/DD/YYYY
Duration: 50 minutes
Subjective: Client reports increased work stress and sleep disturbances
Objective: Observed tension in shoulders, speaking rapidly
Assessment: Adjustment Disorder with Anxiety
Intervention: Introduced progressive muscle relaxation, discussed sleep hygiene
Response: Client receptive to interventions, practiced relaxation in session
Plan: Continue stress management techniques, monitor sleep patterns
Risk Assessment: No current risk of self-harm or suicide
Next Session: MM/DD/YYYY at HH:MM
16. Case Management Note Template and Example
Case management notes focus on coordinating services and addressing various aspects of a client's care.
Here's a long example of a case management note:
Client: John Smith
Date: MM/DD/YYYY
Case Manager: Sarah Johnson, LSW
Presenting Issues:
1. Homelessness - currently staying at local shelter
2. Unemployment - lost job 3 months ago due to mental health issues
3. Unmanaged bipolar disorder - inconsistent with medication
Actions Taken:
1. Housing:
- Completed application for subsidized housing program
- Contacted three local landlords about available units
- Scheduled appointment with housing authority for next week
2. Employment:
- Referred client to vocational rehabilitation services
- Assisted in updating resume and creating LinkedIn profile
- Provided information on upcoming job fair
3. Mental Health:
- Coordinated with psychiatrist to adjust medication schedule
- Arranged transportation to next psychiatric appointment
- Provided education on importance of medication adherence
4. Benefits:
- Assisted in completing SSDI application
- Followed up on pending food stamp application
Client's Response:
- Expressed gratitude for housing assistance
- Showed hesitation about job search due to fear of relapse
- Agreed to try new medication schedule
Barriers Identified:
- Lack of reliable transportation
- Limited social support system
- Cognitive difficulties affecting ability to follow through on tasks
Plan:
1. Follow up on housing applications within 5 business days
2. Accompany client to job fair next month
3. Explore options for peer support groups in the area
4. Schedule meeting with client's sister to discuss potential family support
Next Appointment: MM/DD/YYYY at HH:MM
Goals for Next Session:
1. Review status of housing applications
2. Discuss results of psychiatric appointment and medication adherence
3. Begin creating a weekly schedule to improve structure and routine
17. PIE Note Template and Example
PIE (Problem, Intervention, Evaluation) notes are a concise yet comprehensive way to document therapy sessions. This therapy progress note template is particularly useful for tracking specific issues, the interventions used, and their effectiveness.
Below again is a long, detailed example of a PIE note:
Client: Alex Johnson
Date: MM/DD/YYYY
Session #: 12
Problem:
Client continues to struggle with panic attacks in social situations, particularly when attending work meetings or social gatherings. Reports experiencing 3 panic attacks in the past week, with symptoms including rapid heartbeat, sweating, and fear of losing control. Client expresses frustration with the impact on professional and personal life, stating, "I'm tired of letting this control me."
Intervention:
1. Reviewed and reinforced diaphragmatic breathing technique learned in previous session.
2. Introduced cognitive restructuring to address catastrophic thinking associated with panic symptoms.
- Identified automatic thought: "I'm going to embarrass myself and everyone will think I'm crazy."
- Challenged thought using evidence for and against, developing more balanced perspective.
3. Created a fear hierarchy for gradual exposure to anxiety-provoking social situations.
4. Taught grounding technique using 5-4-3-2-1 sensory awareness exercise.
5. Assigned homework: Practice diaphragmatic breathing and grounding technique daily; complete thought record for panic-inducing situations.
Evaluation:
Client demonstrated good grasp of diaphragmatic breathing technique and was able to use it effectively to reduce anxiety during in-session role-play of a work meeting scenario. Showed initial resistance to cognitive restructuring but engaged more fully after working through an example together. Client expressed relief at having a structured plan (fear hierarchy) for addressing social anxiety and was particularly receptive to the grounding technique.
Progress towards treatment goals: Client showing improved ability to manage acute anxiety symptoms using learned techniques. Gradual exposure plan represents significant step towards addressing avoidance behaviors. Cognitive work still in early stages but client demonstrating increased awareness of thought patterns.
Plan for next session:
1. Review homework and address any challenges encountered.
2. Begin working through fear hierarchy with imaginal exposure.
3. Continue cognitive restructuring work, focusing on core beliefs about social evaluation.
4. Introduce concept of behavioral experiments to test anxious predictions.
Risk Assessment: Client denies any current suicidal ideation, intent, or plan. No signs of self-harm or harm to others observed or reported.
Conclusion
As you can see, progress notes vary in length dramatically. Some therapists take 5-7 minutes to write progress notes, and some take 15-30 minutes per note. Choosing the right template for mental health progress notes can significantly improve your clinical documentation process, enhance communication among healthcare professionals, and ultimately lead to better patient care. By incorporating these psychotherapy progress notes templates into your practice, you can streamline your note-taking process, ensure compliance with regulatory requirements, and maintain a comprehensive record of your clients' progress.
Remember, the best template for you will depend on your specific therapeutic approach, client needs, and practice requirements. Feel free to adapt these templates or combine elements from different ones to create a new template that works best for your unique situation.
By mastering the art of writing effective progress notes, you'll not only improve your clinical documentation but also enhance your ability to provide high-quality mental health services to your clients.
References
https://dmh.lacounty.gov/for-providers/clinical-tools/clinical-forms/progress/
https://www.template.net/business/note-templates/progress-note/
https://dhs.saccounty.gov/BHS/Documents/BHS-Policies-and-Procedures/PP-BHS-QM-10-30-Progress-Notes-%28Mental-Health%29.pdf