A therapy progress note records one psychotherapy session: what the client brought, what you did, how they responded, and what comes next. Copy the free template, see a CBT and a grief counseling example, and check what goes in each part.
Blank therapy progress note template
FreeTHERAPY PROGRESS NOTE Client: [Name or ID] Date of session: [Date] Clinician: [Name, credentials] SESSION DETAILS Session number: [Number in this episode of care] Start and end time: [Times and total minutes] Format: [Individual, couple, or family; in person, video, or phone] Telehealth check: [Client's location, privacy of the setting, emergency contact confirmed] Others present: [Name and relationship, or none] Modality: [CBT, DBT, ACT, EMDR, psychodynamic, person-centered, or other] Diagnosis or focus of care: [As listed in the treatment plan] SESSION FOCUS Client's concerns today: [What the client brought, in their words where it helps] Since last session: [Changes in symptoms, stressors, and functioning at home, work, or school] Homework review: [What was assigned, whether it was done, and what the client noticed] Measures: [Scale and score today, with the previous score] INTERVENTIONS Techniques used: [Name each one: cognitive restructuring, exposure, behavioral activation, skills coaching, processing, psychoeducation] Treatment plan link: [The goal or objective each technique targets] In-session ratings: [Distress, belief, or urge ratings before and after, if used] CLIENT RESPONSE Engagement: [Participation, openness, understanding of the material] Response: [What shifted in session: insight, ratings, skill practice, rapport] Presentation: [Brief mental status: appearance, mood and affect, thought process, orientation] RISK AND SAFETY Suicidal ideation: [Denied, or passive or active, with plan, intent, and access to means] Self-harm and harm to others: [Denied, or details] Protective factors: [Reasons for living, supports, engagement in care] Safety actions: [Safety plan reviewed or updated, consultation, or none needed] PROGRESS TOWARD GOALS Goal progress: [Goal by goal: improving, no change, or worse, with the evidence] Barriers: [What is getting in the way] PLAN Homework: [Practice before the next session, specific enough to do] Next session focus: [What you plan to work on, and why] Coordination: [Referrals or contact with other providers, with the client's consent] Next session: [Date, time, and format] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient practice, individual session, in person
Session 6 of individual CBT, 53 minutes, in person. No one else present. Diagnosis: panic disorder, from the intake assessment. Primary care ruled out heart and thyroid causes before the referral.
34-year-old woman. Reports 2 panic attacks this week, down from 5 a week at intake. One began at a grocery store checkout; she stayed and paid instead of leaving her cart. Still avoids highway driving, and still avoids coffee and exercise because they make her heart race. Panic diary completed on 5 of 7 days. Panic Disorder Severity Scale 11, down from 17 at intake.
Reviewed the panic diary and the cycle of body sensation, catastrophic thought, and fear. Cognitive restructuring of “a racing heart means a heart attack”: belief rated 80% at the start and 35% at the end. Interoceptive exposure for the goal of reducing fear of body sensations: spinning in a chair and breathing through a thin straw, 3 trials each. Introduced the idea of a driving hierarchy.
Engaged and curious. Distress peaked at 70 out of 100 on the first spinning trial and fell to 30 by the third. Said, “It went up, and then it came down on its own.” Well groomed, alert, and oriented. Mood “hopeful”; affect anxious at the start and brighter by the end. Thought process logical.
Denies suicidal ideation, self-harm, and thoughts of harming others. Protective factors: a supportive partner, full-time work, and engagement in treatment. No safety actions needed.
Goal 1, fewer panic attacks: improving, from 5 a week to 2. Goal 2, return to avoided places: partly met; shopping alone again, highway driving not yet tried. Barrier: avoiding caffeine and exercise keeps her fear of a racing heart going.
Homework: spinning and straw breathing daily, 3 trials each, with distress ratings; continue the panic diary; one brisk 10-minute walk. Next session: build the driving hierarchy and plan the first step, a short drive on a quiet road. No coordination needed. Next session in 1 week, in person.
Outpatient counseling, individual session by video
Session 4 of grief counseling, 50 minutes, by video. Client at home, alone in a private room; location and emergency contact confirmed. Person-centered approach with grief-focused work. Focus of care: uncomplicated bereavement.
67-year-old man whose wife died 5 months ago after a long illness. Raised the first holidays without her, 3 weeks away. Sleeping about 6 hours most nights, up from 4. Eating regular meals since he started having dinner with his son twice a week. Has not sorted her clothes and feels guilty about it. Brought the letter to his wife that he wrote as homework. PHQ-9 8, down from 12 at session 1.
Invited him to read the letter aloud, and reflected its themes of guilt and gratitude. Normalized waves of grief and his guilt about her belongings: there is no deadline for sorting them. Used the dual process model of grief to plan a balance of time for grieving and time for rebuilding routines. Planned for the holidays: which traditions to keep, change, or skip, and who he will spend them with.
Tearful while reading, then calmer. Said, “I didn’t know I was allowed to take my time with her things.” Agreed to talk with his son about the holidays. Neatly dressed. Mood “heavy, but okay”; affect sad and reactive, brighter when he spoke about his grandchildren. Thought process goal-directed.
Asked directly, given his recent loss, his age, and living alone: denies thoughts of suicide or of wanting to join his wife, and denies self-harm. No firearms at home. Drinks 1 beer most evenings, unchanged. Protective factors: his son and grandchildren, his faith community, and regular sessions. No safety actions needed; screen again each session.
Goal 1, restore daily routines: improving; sleep and meals are better. Goal 2, reconnect with others: dinners with his son, but he has not gone back to his walking group. Grief is still intense at times, as expected 5 months after the loss.
Homework: list two holiday traditions to keep and one to change, and share the list with his son; join his walking group once. Next session: the holiday plan, and the approaching anniversary of her diagnosis. Next session in 2 weeks by video. He knows to call 911 or go to the nearest emergency department if he has thoughts of ending his life.
What the client brought to this session, and what has changed since the last one.
Avoid: A transcript of the session. Summarize the themes, and quote only what shows the client’s view.
What you did, named precisely enough that another clinician could repeat it, and linked to the treatment plan.
Avoid: “Provided support” or “processed feelings” on their own. Name the technique and what it was for.
How the client engaged and what changed during the session. This is what shows whether the work helped.
Avoid: Leaving it out. Without the response, the note shows what you did but not what it achieved.
A brief screen every session, with more detail when risk is present or has changed.
Avoid: “No risk” with nothing behind it. Record what you asked and what the client said.
Where the client stands on each treatment plan goal, with evidence.
Avoid: “Making progress” with no evidence. Point to something you or the client can measure.
What happens between now and the next session, and at it.
Avoid: “Continue therapy” as the whole plan. Say what you will work on next, and why.
A progress note is part of the clinical record, which the client may read and others may receive with consent. Record themes, interventions, and response, not every detail the client disclosed.
If the plan says CBT for panic but the notes describe general support, the record doesn’t show why the sessions are needed. Link each intervention to a goal.
Ask about risk each session and record the answer. Last week’s “denies SI/HI” pasted into today’s note is not a screen.
Words like “resistant,” “noncompliant,” or “manipulative” judge rather than describe. Write what happened: “did not complete the diary; said she forgot on busy days.”
Write the note the same day if you can. If it’s late, label it as a late entry with the date you wrote it.
Vero Scribe writes the progress note in your template from the session, with the client’s consent, or from your dictation afterward. You review and edit it, then copy it into your record or export it as a Word or PDF file.
The session’s date, length, and format; what the client brought; the interventions you used; how the client responded; a risk screen; progress toward treatment plan goals; and the plan for the next session.
Yes. DAP, BIRP, and SOAP are all formats for progress notes. This template follows the session in order instead, which suits clinicians who want the interventions and the client’s response to stand out.
As soon as you can after the session, ideally the same day, while the details are fresh. If you write it later, label it as a late entry with the date you wrote it.
In most places, clients have a right to see their record, with limited exceptions. Write each note as if the client may read it: factual, respectful, and free of jargon.
Usually a few short paragraphs. Include enough to show what you did, why, and how the client responded, and leave out session content the care doesn’t need.
Yes. Copy it, or download it as a Word or text file. No account needed.
SOAP for therapy sessions, with mental status observations and PHQ-9 and GAD-7 scores.
The first session: consent, history, risk, mental status, screening scores, and recommendations.
Biological, psychological, social, and cultural factors, brought together in one formulation.
Problems, goals, measurable objectives, interventions, and review dates, agreed with the client.
One note per member: the group’s topic and interventions, then that member’s participation and plan.
Session examples in three common note formats.
An eight-step workflow, examples, and a quality checklist.
Intake and progress notes drafted from your sessions, for you to review.
The MSE domains, and how to document each one.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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