Psychotherapy Progress Notes Template

.progress_note

Client Details
– Client Name:

Client Full Name

– ID Number:

Client ID Number

– Date of Session: Month: 01/Day: 01/Year: 2001
– Time of Session: Hour: 01 (00-23):Minute: 01 AM/PM - Hour: 01 (00-23):Minute: 01 AM/PM
– Type of Session:

Individual, Group, Family, Couples

– Therapist:

Therapist Name

Problem
– Presenting Problem:

Brief description of the issue(s) the client is experiencing, as reported by the client or observed by the therapist.

– Symptoms:

List any symptoms or behaviors that the client has reported or that have been observed.

– Duration:

Length of time the client has been experiencing the problem.

– Severity:

Assessment of the problem’s severity and impact on the client’s daily functioning.

Assessment
– Mental Status Examination (MSE):

Brief summary of the client’s appearance, behavior, thought process, mood and affect, speech, perception, cognition, insight, and judgment.

– Diagnosis (if applicable):

Current DSM-5 diagnosis or diagnostic impressions.

– Risk Assessment:

Evaluation of any risks to self or others, including suicidality, self-harm, or aggressive behaviors.

Intervention
– Therapeutic Interventions:

Description of the therapeutic techniques and strategies used during the session, such as CBT, DBT, psychodynamic therapy, etc.

– Client Participation:

Observations on how the client engaged with the intervention; e.g., level of participation, reactions, and openness to the process.

– Progress Made:

Evaluation of the client’s progress in relation to the therapeutic intervention

Medication
– Current Medication:

List of any medications the client is taking, including dosages and frequency.

– Medication Compliance:

Note on whether the client is taking their medication as prescribed.

– Side Effects:

Any side effects the client is experiencing from the medications.

– Medication Changes:

Any changes in medication, including dosage adjustments or medication switches.

Plan
– Treatment Goals:

Review and update of short-term and long-term goals.

– Next Steps for Therapy:

Outline the focus for future sessions and any changes to the therapeutic approach.

– Homework/Outside Assignments:

Any tasks or activities the client is asked to complete before the next session.

– Follow-Up:

Details concerning scheduling the next appointment or any other follow-up procedures.

– Additional Notes:

Any other relevant information that doesn’t fit into the above categories.

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