THERAPY 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]