Marissa Moore • 2023-03-21
Have your progress notes written for you automatically
Writing progress notes may be a dreaded part of your day if you're a mental health professional. You may wonder what a progress note should look like or what template you should use.
When you are writing therapy progress notes, there isn’t one template that is recommended. Many insurance companies require you to state what interventions you’re using and why the client needs therapy—otherwise known as medical necessity. This is easy when you have well-documented reasons why the client is seeing a mental health professional, and you use sound clinical practices.
If you want to know what common templates or formats for your mental health progress notes look like. Here are 15 examples you can use.
A SOAP note is a common note template that many mental health professionals use to document their sessions. A SOAP note has four sections and an example is provided below.
Subjective: The client presents for therapy, wanting to work on symptoms associated with their Borderline Personality Disorder diagnosis. The client reports having trouble with their interpersonal relationships and often feels like the people close to them will abandon them. The client says they struggle to relate to their coworkers and maintain friendships. The client states they have had these problems throughout their life but noticed the relationship difficulties increasing in the last few months.
Objective: The client presents with a disheveled appearance. They are on time for the session and have a depressed presentation. The client appears in a low mood.
Assessment: The client appears to meet the Borderline Personality Disorder criteria. They have a history of challenges with maintaining friendships, which has increased in the last few months with increased stress.
Plan: The client will meet with the therapist weekly to work on symptoms associated with Borderline Personality Disorder. The therapist will utilize DBT techniques such as helping the client learn interpersonal effectiveness skills. In addition, the therapist will work towards helping the client identify a DBT group in the area they can join.
DAP notes have three short sections so it’s easy to track a client’s progress. An example of a DAP note is below for a client with ADHD.
Data: The client presents for psychotherapy due to struggling to focus on his college classes. The client finds they procrastinate and need help completing their homework by assigned deadlines. The client has consistently been late in turning in homework since the semester began. He also reports problems getting to class on time since the semester started three months ago.
Assessment: The client’s symptoms are consistent with ADHD. The counsellor will work with him on strategies to help with task initiation as well as recognizing unhelpful thoughts he may be having that inhibit his ability to get his work done. The counsellor will also speak with him about getting a formal assessment done for ADHD and potential medication.
Plan: The client will meet with the counsellor weekly to work on strategies for coping with ADHD. The counsellor will give him an outside referral to a Psychologist who does ADHD testing.
BIRP notes are behavior-focused notes that have four sections. A BIRP note example for trauma is provided below.
Behavior: The client presents for therapy to work on challenges related to childhood trauma. The client reports that they are having flashbacks and nightmares regarding a sexual abuse incident that occurred in childhood. Additionally, the client reports that these nightmares have affected their sleep quality, causing fatigue issues during the day.
Intervention: The counsellor will utilize EMDR techniques to help treat the client’s trauma. The counsellor spent the first part of the session identifying coping skills and resources they use to process trauma and what hasn’t helped.
Response: The client was on time for therapy and attentive. The client is receptive to starting EMDR, which will begin in the next session.
Plan: The client and counsellor will start working on the first phase of EMDR in the next session. The counsellor and client will meet weekly to work on the client’s past trauma.
GIRP notes are goal-focused notes that have four sections. A GIRP note example is provided below.
Goal: The client presents for therapy, wanting to work on several life stressors. The client presents for treatment due to several recent changes they are having trouble adjusting to. The client reports they just got married and started a new job. The changes they’re facing are causing a lot of stress and exhaustion.
Intervention: The counsellor will work with the client on developing 3-5 strategies for reducing and coping with stress. The counsellor will allow the client space to discuss and process how stress impacts them.
Response: The client states they “are happy to start therapy and work on stress management skills.” The client is attentive and focused in the therapy session.
Plan: The counsellor will meet with the client bi-weekly to address stress management techniques. The client’s next session is Friday at 10 a.m.
PIRP notes are problem-focused notes that have four sections. An example of a PIRP note is included below.
Problem: The client presents for therapy and states her problems include meth use and depression. The client reports, “meth use has ruined my relationships with others.” The client struggles to pay her bills and says she has been clean from methamphetamine for one week. The client would like to work on assistance with paying her bills and identifying additional recovery resources to help her continue abstaining from meth use.
Intervention: The therapist utilized motivational interviewing techniques to assess their substance use history and readiness to change. The therapist helped the client explore triggers for using methamphetamines. The therapist gathered a history of the client’s depressive symptoms, and the client states they have been depressed for about two years when their methamphetamine use increased.
Response: The client appears to be in the action stage of change with their methamphetamine use. The client reports they are motivated to stay clean and learn more about their depression and substance use.
Plan: The client will attend weekly therapy sessions with the therapist. The client will attend one NA group per week. The therapist will refer the client to have services with a caseworker who can help them address assistance resources for paying their bills.
This note doesn’t follow a specific template, but includes necessary and relevant information for billing and insurance purposes.
Mental status: The client presents with a euthymic mood. The client appears well-dressed and speaks at an average volume and pace. The client is oriented to person, place, and time.
Risk assessment: The client presents no significant risk of harming themselves or others.
Presenting Problem: The therapist and client have been working to address problems in communication in their relationships with their partner and friends. They are working on using “I” statements.
Assessment: The client reports difficulty in their relationships before engaging in therapy. The therapist has been educating the client about healthy relationships in prior sessions. The client says that they have been able to utilize “I statements” when bringing up difficult conversations with their partner.
Therapist intervention: The therapist has provided the client with psychoeducation on healthy communication skills and introduced them to Gottman’s Four Horsemen of the Apocalypse.
Plan: The client is progressing in therapy and will probably need two more sessions to complete their work. The client will meet with the therapist next week and the following week and then terminate treatment at this time.
Case workers or case managers may work on areas related to a client’s mental health, but their focus is a little different than a typical mental health clinician.
Problem: The client presents for case management services to work on finding housing and applying for food stamps. The client reports that they were able to obtain the paperwork on their own but need help filling it out. The client has been staying in a homeless shelter, and would like to find their own place.
Treatment plan goal: The client will obtain housing and food assistance.
Intervention: In this session, the case manager was able to spend an hour assisting the client with filling out applications for food stamps and low-income housing. The case manager educated the client on where to turn in filled out applications and provided them with transportation to the community service agency.
Client response: The client filled out their applications and expressed gratitude for the assistance of the case manager.
Plan: The case manager will meet with the client bi-weekly to help the client track the progress of their applications and if denied help them access other community resources.
CBT Notes can use other note formats to document the therapy session. In this example, there is CBT interventions using a SOAP note format.
Subjective: The client presents for therapy due to social anxiety. The client states they don’t like leaving their house because they don’t want to interact with people they don’t know. In addition, they often have to lead meetings and give presentations at work, making them feel jittery. The client reports poor sleep quality and work difficulties due to social anxiety.
Objective: The client has an anxious presentation. They are talking rapidly during the session. The client appears nervous and anxious while speaking with the psychotherapist.
Assessment: The client has symptoms consistent with social anxiety disorder. The psychotherapist will monitor their anxiety symptoms through the Liebowitz Social Anxiety Scale. The psychotherapist will work with the client utilizing CBT methods to identify and replace irrational thoughts. The psychotherapist will also work with the client to help them identify cognitive distortions and how these distortions may effect their life.
Plan: The psychotherapist and client will meet weekly for therapy. The client will keep a CBT thought log of their anxious thoughts to review in each session.
Couples therapy notes are different than individual therapy notes as they focus on the dynamic between two people who are in relationship or marriage. Many couples come to therapy to work on improving their relationship through the work they do in couples therapy. An example of a couples psychotherapy note is outlined below.
Presenting Problem: The couple presents for therapy wanting to work on communication differences. The couple reports that when they try to communicate they often end up yelling at each other which results in no teamwork to accomplish their goals or solve problems. They state that they both end up shutting down which leads to an emotional disconnect. They state they want to work towards communicating better and finding ways to resolve conflict.
Themes and patterns identified: The social worker observed that the couple tends to sit far away from each other session. They appear physically and emotionally disconnected. The couple has insight into their challenges with ineffective communication, and report that the yelling and disrespectful communication increases when they are both stressed.
Discussion: The couple shuts down when they feel disrespected. They use stonewalling often to communicate a message, but this method drives them further apart as it doesn’t resolve the issue. The “silent treatment” then begins to feel like a punishment to them both, and they never talk about the issue again.
Plan: The social worker addressed and provided education to the couple about Gottman’s Four Horseman of the Apocalypse in session. The couple voiced understanding about what this means and were able to identify some examples of how this shows up in their relationship. The social worker will educate them on the antidotes to the four horsemen in the next session.
Homework: The couple was encouraged to write down any incidents of the four horseman appearing in their day to day life before the next session.
PIE notes are short progress notes that are problem focused. Below is an example of what a PIE Note may look like for an adolescent.
Problem: ****The adolescent presents for a therapy session with reports of falling behind in school. The client reports that they have always been a straight A student, but their grades have worsened this year, which has been happening for about six months. They report an increase in the difficulty of their schoolwork. They say they have trouble focusing at school and home and avoid their homework because they find it challenging. The client states that when they are at school, the environment is “too loud to focus.”
Intervention: The counselor will work with the client on reducing the symptoms of ADHD. The counselor will work with the adolescent’s parents and school with permission from the client’s parents to request accommodations for the client at school. The counselor will educate the client on some strategies they can use to manage their ADHD. The counselor will also provide psychoeducation to the client and their parents on tools to help the client manage their ADHD.
Evaluation: The client’s symptoms are consistent with a diagnosis of ADHD. The client was receptive to this and the client and parents are on board for learning new strategies and working with the school.
Play therapy notes follow various formats. It’s important to talk about how the child engaged in play therapy and what interventions you used. A play therapy note may follow a similar format as below.
Presenting problem: The child presents for therapy because the parents state the child throws more tantrums at home. The child is eight years old and in 2nd grade. The parents report the child is doing well in school but at home is refusing to clean their room and throwing tantrums when asked to do something. The parents say they want the child to learn to manage their emotions better.
Techniques: The Psychologist will provide client-centered play therapy techniques with the child to help the child work on better identifying and managing emotions. The Psychologist utilized tracking and limit setting during this session to help the client identify emotions.
Response: The child was shy and reluctant to engage in play therapy at first. The client then played with the dollhouse the majority of the session. The client preferred independent play, and shut down when the Psychologist talked about how the dolls might be feeling.
Plan: The Psychologist will continue to meet with the child weekly for play therapy. The Psychologist will continue to work towards building trust and rapport with the client.
Group therapy notes are different than individual or couples therapy notes. They document what occurred in the group as a whole, and how the individual responded to the group facilitator and other members of the group. An example of a group therapy progress note for substance use is supplied below.
Group focus: The group focus today was identifying triggers to substance use. Identifying triggers for substance use is key in relapse prevention, and helps the group identify barriers to sobriety.
Client mood: The client presented with depressed mood.
Group facilitator interventions: The group facilitator encouraged the group to identify triggers that lead them to use drugs. The group facilitator encouraged sharing about their triggers to help them process what triggers they have. The group facilitator assisted the group members with identifying how the group members could respond to their triggers and make different choices or avoid their triggers altogether. The group members actively engaged in a discussion about avoidable and unavoidable triggers.
Individual response to group: The client responded well to the group discussion and was able to share about her triggers. She had to be prompted to engage at first, but then was an active participant in the group after some encouragement. ****
Plans and Recommendations: The group facilitator recommends that the client continue to attend group sessions on a weekly basis. The group facilitator also recommends that the client still attends individual therapy sessions weekly to address depression.
Custom progress notes can be tailored for each individual clinician. They don’t have to follow these sections but here's an example that includes a strengths section.
Presenting problem: The client presents for therapy, wanting to work on steps to come to terms with their sexuality. They report accepting parents but struggle with coming out to their extended family for fear of judgment. The client says they have moderate anxiety and would like some strategies for dealing with it.
Mental Status: The client presents with an anxious presentation. The therapist can sense that it is difficult for the client to attend therapy and discuss their sexuality.
Assessment: The client appears to have anxiety and seems nervous about discussing their sexuality in depth in the first session. The client will likely need to build trust and rapport with the therapist before digging into family history and coping.
Intervention: The therapist will educate the client on the stages of coming out. The therapist will first work to develop trust and rapport with the client. When the client is more trusting of the therapist, the therapist will use ACT techniques to help the client respond to coming out.
Strengths: The client can ask for help and has a strong support system consisting of friends and parents.
Areas to work on: The client is anxious and may have difficulty opening up initially.
Plan: The therapist and client will meet weekly.
This first note delivered by Mentalyc AI has eight sections optimized for easy readability and to meet industry standards. This standardized note format meets the requirements for medical necessity and provides evidence-backed interventions, which make it easy to track client progress.
Presentation: The client struggles with physical back pain, difficulty organizing their business, and anxiety due to company funding. They report tiredness and feeling down, frustrated, and overwhelmed due to their son’s lack of understanding of financial matters. They have a jelly-like feeling and difficulty finding a comfortable position to relax in, neck pain and muscle issues for some time, and anxiety related to their age and the impact of a recent fall. These issues have been present for varying lengths, resulting in adverse functional effects on the client’s life.
Intervention: The therapist introduced imagery exercises, writing down dreams, setting up an email account, visualizing a black dot, imagining a movie theater screen with a number one on it, stepping into the number one, being specific when asking for help, and not comparing themselves to their son. The therapist introduced them to imagine walking in a forest and growing their head above the canopy of trees, magic Egyptian hand massage techniques, and breathing exercises to help the client manage their anxiety and relax. These interventions have been effective in helping the client improve their situation.
Progress: The client and therapist have agreed on goals to manage the client’s anxiety through visualization techniques, be more specific when asking for help from his son, and write down their dreams. The client has demonstrated improvement in managing his anxiety and was receptive to the therapeutic interventions suggested by the therapist.
Response: The client responded positively to the therapeutic interventions, willingly accepting and engaging. They felt relaxed after engaging in the exercises and were interested in continuing with similar activities in future sessions. Examples of accepted interventions included imagery exercises, writing down dreams, and setting up an email account for accounting purposes.
Goals: The client and therapist will work together to address the client’s anxiety, sleep issues, and financial concerns, as well as explore the client’s dream to gain clarity into what they have and don’t have and where they should focus their attention.
Risk: The client has expressed hopelessness, worthlessness, and guilt. They have also reported difficulty sleeping and a lack of interest in activities they used to enjoy. These symptoms may indicate an increased risk of suicide or self-harm.
Plan: The therapist suggested the client write down their dreams, set up an email forwarding system for all of the Kimble companies, look up alarm clocks that imitate sunrise, be specific when asking for help from his son, use his imagination to explore his feelings, and use imagery to help relax and explore their dream. The therapist also suggested exercises such as magic Egyptian hands, breathing with the trees, and walking in a forest with open eyes.
Homework: The client was asked to practice various activities at home, that were suggested by the therapist.
This AI-generated note helps succinctly summarize information that the client reported in session. This progress note is easy to read and helps the reader understand the clients progress and the actions of the therapist.
The client is making progress in their sobriety and understanding their feelings around abandonment. However, they still struggle with these feelings at times, particularly when they are under stress. The client is also making progress in terms of reducing their anxiety and stress levels, as well as beginning to allow themselves to feel more of their emotions. However, the client still needs to work on letting go of the need to fix everything for other people and accepting that they cannot control everything.
The client responds well to the therapist's interventions, is able to see how their thinking has changed, and begins to implement them into their life. The client reports feeling a sense of relief after working through some of the issues.
If you want to streamline your note-taking and make writing progress notes easier, consider signing up for Mentalyc. Mentalyc’s AI technology can help you record your sessions and write notes so you have more time to focus on what matters to you. With an average of 2 minutes to write a progress note, this can save you time and headaches. Don’t hesitate; get started with Mentalyc today!
Marissa Moore is a mental health professional who owns Mending Hearts Counseling in Southwest Missouri. She specializes in providing affirming counseling services to the LGBTQIA+ community. Marissa has 11 years of experience working in the mental health field, and her work experience includes substance use treatment centers, group homes, an emergency room, and now private practice work.
All examples of mental health documentation are fictional and for informational purposes only.
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