Top 11 Therapy Progress Note Templates with ExamplesUpdated: November 08, 2023
Therapy progress notes and psychotherapy notes are crucial for documenting patient interactions, monitoring progress, and guiding future treatment plans. They not only serve as a record but also as a guide for therapeutic interventions and client outcomes.
This article breaks down therapy progress notes and psychotherapy notes and provides illustrative examples to enhance your clinical documentation.
What are Therapy Progress Notes?
Progress notes are written records by mental health professionals documenting the details of a session with a client. They provide insights into a client’s well-being, the interventions utilized, and the subsequent plan of action.
These notes assist in monitoring the client’s progression, ensuring continuity of care, and are often required for insurance and legal purposes.
Types of Therapy Progress Notes
Several established formats help therapists document client interactions. Among these, the most common are:
- DAP (Description, Assessment, Plan): Focuses on describing the session, assessing the client’s status, and planning the next steps.
- BIRP (Behavior, Intervention, Response, Plan): Outlines observed behaviors, therapeutic interventions, client’s response, and plans.
- SOAP (Subjective, Objective, Assessment, Plan): Begins with the client’s subjective report, followed by objective observations, assessments, and plans.
- GIRP (Goal, Intervention, Response, Plan): Centers on the client’s goals, interventions applied, the client’s response to those interventions, and future planning.
- PIRP (Problem, Intervention, Response, Plan): Details the client’s primary problem, the therapeutic interventions implemented, the client’s response to the interventions, and the ensuing plan.
- RIFT (Reason, Intervention, Feedback, Therapy goals): Starts with the reason for the client’s visit, describes the interventions used, includes client and therapist feedback, and outlines the goals of therapy.
- CARE (Client, Assessment, Response, Evaluation): Focuses on the client profile, an assessment of the client’s needs, responses in sessions, and an evaluation of progress.
- STOP (Summary, Treatment, Observation, Plan): Provides a summary of the client’s condition, the treatment provided, observations made during the process, and the plan for continuing care.
- MINT (Motivation, Issues, Next steps, Therapeutic tools): Emphasizes the client’s motivation, current issues or challenges being faced, next steps in therapy, and the therapeutic tools or strategies to be utilized.
- FORT (Focus, Outcome, Response, Tactics): Involves identifying the focus of the session, desired outcomes, client’s responses to interventions, and tactics for achieving therapeutic goals.
What Should Be Included in Therapy Progress Notes?
In the course of therapy, every session possesses unique elements. However, there are standard components that need to be consistently recorded for coherence and clarity:
- Demographic/Identifying Information: Includes name, age, session date, and other relevant details.
- Description of Your Client’s Behavior: Record observations, verbal interactions, and non-verbal cues.
- Treatment Plans Going Forward: Document potential interventions, modifications, and future goals.
Therapy Progress Notes Templates
Here are some templates that incorporate the essential components of a therapy session, along with their specific therapy note formats:
DAP Template Copy Snippet Copied!
Date of Session:
BIRP Template Copy Snippet Copied!
Date of Session:
SOAP Template Copy Snippet Copied!
Date of Session:
GIRP Template Copy Snippet Copied!
Date of Session:
PIRP Template Copy Snippet Copied!
Date of Session:
RIFT Template Copy Snippet Copied!
Date of Session:
Reason for the session:
Feedback from the client:
Therapy goals for the next session:
CARE Template Copy Snippet Copied!
Date of Session:
Client’s main concern:
Assessment of progress:
Response to intervention:
Evaluation of the session’s effectiveness:
STOP Template Copy Snippet Copied!
Date of Session:
Summary of the session:
Plan for the next session:
MINT Template Copy Snippet Copied!
Date of Session:
Therapeutic tools utilized:
FORT Template Copy Snippet Copied!
Date of Session:
Focus of session:
Tactics for the next session:
Therapy Progress Note Template Examples
1. DAP Example
Client’s Name: John Doe
Date of Session: 10/25/2024
Session Number: 5
Description: John discussed feelings of sadness since the loss of his job.
Assessment: Symptoms of moderate depression.
Plan: Begin exploring coping mechanisms.
2. BIRP Example
Client’s Name: Jane Smith
Date of Session: 10/26/2024
Session Number: 8
Behavior: Avoidant when discussing childhood.
Intervention: Used open-ended questions.
Response: Became tearful but shared more details.
Plan: Delve deeper into childhood experiences.
3. SOAP Example
Client’s Name: Robert Lee
Date of Session: 10/27/2024
Session Number: 12
Subjective: “I feel constant anxiety at work.”
Objective: Elevated heart rate when discussing work situations.
Assessment: Signs of generalized anxiety disorder.
Plan: Address triggers at work.
4. GIRP Example
Client’s Name: Emily Stone
Date of Session: 10/28/2024
Session Number: 3
Goal: Improve self-esteem.
Intervention: Positive affirmation exercises.
Response: Felt a bit skeptical but willing to try.
Plan: Monitor the impact of affirmations.
5. PIRP Example
Client’s Name: Michael Brown
Date of Session: 10/29/2024
Session Number: 9
Problem: Struggles with anger outbursts.
Intervention: Taught deep breathing techniques.
Response: Found it helpful during minor irritations.
Plan: Tackle larger anger triggers.
6. RIFT Example
Client’s Name: Sarah White
Date of Session: 10/30/2024
Session Number: 15
Reason for the session: Recurring nightmares.
Intervention: Dream analysis.
Feedback from client: Felt relieved to discuss.
Therapy goals for the next session: Continue dream journaling.
7. CARE Example
Client’s Name: Liam Clark
Date of Session: 10/31/2024
Session Number: 6
Client’s main concern: Difficulty connecting with adult children.
Assessment of progress: Possible communication breakdown.
Response to intervention: Open to learning communication techniques.
Evaluation of session’s effectiveness: Positive, client felt understood.
8. STOP Example
Client’s Name: Olivia Green
Date of Session: 11/01/2024
Session Number: 10
Summary of the session: Discussed recent divorce and its impact on self-worth.
Treatment provided: Supportive counseling.
Observations: Tearful but hopeful.
Plan for next session: Strengthen self-worth through cognitive restructuring.
9. MINT Example
Client’s Name: Ethan Harris
Date of Session: 11/02/2024
Session Number: 4
Motivation level: Moderate.
Issues addressed: Procrastination at work.
Next steps: Identify the main procrastination triggers.
Therapeutic tools utilized: Goal-setting worksheet.
10. FORT Example
Client’s Name: Sophia Gray
Date of Session: 11/03/2024
Session Number: 20
Focus of session: Retirement anxieties.
Expected outcome: Greater peace about the future.
Client’s response: Appreciative of the session.
Tactics for the next session: Explore potential hobbies and activities.
Psychotherapy Progress Notes
It is essential to distinguish between psychotherapy notes and regular therapy progress notes. Both play a crucial role in the treatment process, but they serve different purposes and are treated distinctly in terms of privacy and access.
- Psychotherapy Notes: Used for the therapist’s personal reflections, contain speculative thoughts and observations.
- Therapy Progress Notes: Used to document the client’s treatment, including symptoms, interventions, and progress.
- Psychotherapy Notes: Subjective impressions, personal hypotheses, and potentially sensitive information.
- Therapy Progress Notes: Factual, objective information regarding client sessions, diagnosis, and treatment plan.
- Psychotherapy Notes: Highly protected, not shared with third parties, more privacy under laws like HIPAA.
- Therapy Progress Notes: Part of the official medical record, can be reviewed by insurers and other healthcare providers.
- Psychotherapy Notes: Generally for the therapist’s use only and not included in client’s medical or billing records.
- Therapy Progress Notes: Accessible to a broader range of healthcare and administrative personnel for continuity of care.
Legal and Clinical Use:
- Psychotherapy Notes: Not required by insurers, do not typically contribute to treatment decisions by other providers.
- Therapy Progress Notes: Used to substantiate billing claims, support clinical decisions by other providers, and as legal documents.
- Psychotherapy Notes: Informal, may be more detailed and expansive, capturing the nuances of the therapeutic process.
- Therapy Progress Notes: Formal and standardized, concise, focus on essential information for clinical utility.
Psychotherapy Progress Notes Template Copy Snippet Copied!
– Client Name: [Client Full Name]
– ID Number: [Client ID Number]
– Date of Session: [Date]
– Time of Session: [Start Time – End Time]
– Type of Session: [Individual, Group, Family, Couples]
– Therapist: [Therapist Name]
– 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.]
– 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.]
– 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.]
– 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.]
– 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.]
Psychotherapy Notes Example
- Client Name: Jane Doe
- ID Number: 0011223344
- Date of Session: November 6, 2023
- Time of Session: 10:00 AM – 11:00 AM
- Type of Session:
- Individual Therapist: Dr. John Smith
- Presenting Problem: Client reports increased anxiety and difficulty sleeping, especially in the context of recent marital issues.
- Symptoms: Nervousness, restlessness, fatigue, and irritability.
- Duration: Symptoms have been present for approximately 3 months but have worsened over the past 2 weeks.
- Severity: Client indicates that these issues are starting to interfere with her work performance and social relationships.
- Mental Status Examination (MSE): Client is well-groomed and alert with coherent speech. Displays a flat affect with occasional tearfulness. Reports concentration difficulties but is oriented to time, place, and person. Insight and judgment appear intact.
- Diagnosis (if applicable): Generalized Anxiety Disorder (GAD), DSM-5 code 300.02.
- Risk Assessment: Client denies current suicidal ideation, intent, or plan. No history of self-harm. Denies aggressive tendencies.
- Therapeutic Interventions: Introduced Cognitive Behavioral Therapy (CBT) techniques focusing on identifying and challenging negative thought patterns, along with the introduction of relaxation and mindfulness exercises.
- Client Participation: Client was initially hesitant but became more engaged as the session progressed. She was able to identify several irrational beliefs contributing to her anxiety.
- Progress Made: Client reports a slight reduction in anxiety during the session after practicing breathing exercises.
- Current Medication: Zoloft 50 mg daily in the morning.
- Medication Compliance: Client is compliant with her medication regimen.
- Side Effects: Client reports mild nausea with medication intake.
- Medication Changes: None at this time. Monitoring the need for potential adjustment.
- Treatment Goals: To reduce anxiety symptoms by 50% and improve sleep quality within the next month.
- Next Steps for Therapy: Continue to use CBT techniques for anxiety management. Client to maintain a sleep journal.
- Homework/Outside Assignments: Client to practice deep breathing exercises twice daily and to record anxious thoughts in a journal.
- Follow-Up: Next appointment scheduled for November 13, 2023, at 10:00 AM.
- Additional Notes: Client is encouraged to engage in moderate physical activity to aid in anxiety reduction and improve sleep. Will coordinate with her psychiatrist to discuss the current medication’s effectiveness and side effects.
Therapy progress notes, alongside psychotherapy notes, form the backbone of effective treatment documentation. These templates afford therapists a systematic method for recording client encounters, ensuring that crucial information is clearly communicated and consistently noted.
It’s important to customize these documents to suit the specific requirements of your practice, balancing the structured nature of progress notes with the more nuanced, reflective elements of psychotherapy notes. Remember, the core purpose of both types of notes is to enhance the quality of care provided to clients, ensuring their therapeutic journey is well-charted and thoughtfully considered.
Try it for yourself
With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.
With TextExpander, you can store and quickly expand snippets anywhere you type. That means you'll never have to misspell, memorize, or type the same things over and over, ever again.Try TextExpander FREE for 30 days
Less Repetition, More Customer Delight
TextExpander gives your team the power to do what they do best — faster.