Top 11 Therapy Progress Note Templates with Examples

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.

Writing efficient therapy progress notes is crucial for maintaining accurate records while optimizing the time spent on documentation. Here are five key tips to help you write clear, concise, and effective progress notes:

1. Be Concise but Comprehensive:

• Use clear, succinct language: Avoid jargon and write in plain language to ensure clarity.
• Focus on key points: Highlight significant events, client responses, and changes in behavior or mood.

2. Use Established Formats:

• Follow structured templates: Utilizing formats like DAP, SOAP, or BIRP can streamline your note-taking process.
• Consistency is key: Stick to one format to ensure uniformity and ease of review.

3. Include Objective Observations:

• Record observable behaviors: Note what you see and hear, not just what the client reports.
• Avoid subjective language: Use objective descriptors instead of interpretive language.

4. Outline Future Plans:

• Set clear goals: Define the objectives for future sessions.
• Plan interventions: Outline the strategies you intend to use to address the client’s needs.

5. Maintain Confidentiality:

• Be mindful of sensitive information: Ensure that personal and sensitive details are documented in a way that respects client privacy.
• Use secure systems: Store notes in compliance with privacy regulations like HIPAA.

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 come in various formats, each offering unique benefits for clinical practice. Here are some common types of notes and templates for easy documentation.

• 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.

Below, you will find templates to get started and examples that incorporate the essential components of a therapy session.

1. DAP Example

Client’s Name: John Doe
Age: 32
Gender: Male
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
Age: 28
Gender: Female
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
Age: 45
Gender: Male
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
Age: 21
Gender: Female
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
Age: 38
Gender: Male
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
Age: 29
Gender: Female
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
Age: 50
Gender: Male
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
Age: 40
Gender: Female
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
Age: 27
Gender: Male
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
Age: 55
Gender: Female
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.

Are progress notes the same thing as psychotherapy 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.

Purpose:

• 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.

Content:

• Psychotherapy Notes: Subjective impressions, personal hypotheses, and potentially sensitive information.
• Therapy Progress Notes: Factual, objective information regarding client sessions, diagnosis, and treatment plan.

Privacy:

• 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.

Access:

• 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.

Documentation Style:

• 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.

Client Details

• 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

Problem

• 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.

Assessment

• 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.

Intervention

• 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.

Medication

• 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.

Plan

• 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.