Therapy progress note template, with a session example
Used by: Psychiatrists, psychologists, therapists, counselors and social workers after each session.
A therapy progress note records the clinical content of a session for the treatment record: what was addressed, the interventions used, how the client responded, risk, and the plan. It is different from psychotherapy process notes, which some clinicians keep separately for their own use.
The template, section by section
Session information
Session type, length and who attended.
- Modality (individual, family, group)
- Session length
- Participants
Presentation and content
Mood, affect and the themes the client brought, in brief.
- Client report since last session
- Themes addressed
- Mental status observations
Interventions
What you did, named by technique.
- Interventions and techniques
- Homework reviewed or assigned
Response and progress
How the client responded and progress toward treatment goals.
- Response to interventions
- Progress toward each goal
- Measures (for example PHQ-9, GAD-7)
Risk
Suicide, self-harm and safety screening, with your assessment.
- Suicidal or homicidal ideation
- Protective factors
- Safety plan status
Plan
Next session, focus and any coordination.
- Next session and frequency
- Focus for next session
- Coordination of care
Therapy progress note example
A synthetic example written for an invented patient. It is not a real patient record or medical advice.
Session
Individual psychotherapy, 53 minutes, in person.
Presentation
Client reports a better week at work and two panic episodes, both shorter than before. Mood "okay," affect anxious early in session and brighter by the end. Speech and thought process normal. Oriented and engaged.
Content and interventions
Reviewed the panic log; both episodes followed avoidance of a team meeting. Used cognitive restructuring on the belief "everyone will see I am panicking," identifying evidence for and against. Practiced paced breathing in session. Planned a graded exposure step: attending the full weekly meeting.
Response and progress
Client generated two balanced alternative thoughts with prompting and rated belief in the original thought down from 80 to 45 percent. GAD-7 today 11 (14 four weeks ago). Progress toward goal 1 (reduce panic frequency) and goal 2 (return to meetings).
Risk
Denies suicidal ideation, intent or plan, and homicidal ideation. Protective factors: partner, work, future orientation. No change to risk level.
Plan
Weekly sessions. Homework: panic log and the meeting exposure step. Next session: review exposure and continue restructuring.
Tips from practice
- Name interventions by technique; it shows medical necessity and the treatment approach.
- Tie progress to the goals in the treatment plan.
- Document risk screening every session, including when it is negative.
- Keep content brief; the note is part of the record the client may request.
Let the note write itself in this format
Scribeable writes the note from the visit in the template you choose and suggests the codes, and each sentence drawn from the visit links back to where it came from. You review and sign.
14-day Pro trial, no credit card required. Everything in Pro, including Rounding, for up to 150 notes. To keep Pro after day 14, subscribe for $79/month plus applicable tax. If you don't, nothing is charged and your account becomes read-only, with every note kept.
Questions
- What is the difference between a progress note and a psychotherapy note?
- Progress notes are part of the medical record. Psychotherapy notes, under HIPAA, are a therapist’s separate process notes about the session and are kept apart from the record.
- Can I use a DAP or SOAP format instead?
- Yes. DAP (Data, Assessment, Plan) and SOAP are both common for therapy progress notes; see the DAP note template.
- Can an AI scribe write therapy notes?
- Yes. Scribeable writes therapy progress notes from a recorded session with templates for psychiatry and behavioral health, and you review and sign each note.
Reviewed 2026-11-08.