What this template adds to a basic progress note
Any progress note says what happened in a session. A mental health progress note also carries the clinical checks that make the record defensible: a brief mental status, a risk statement, and a standardized measure scored on the same scale each time. Those three items are what change week to week, and they're what an auditor or a covering clinician scans for first.
The layout here is for an ongoing individual therapy client. It assumes the intake assessment, diagnosis and treatment plan already exist, and refers back to them.
Which mental health note do you need?
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|---|
Routine individual therapy session | Mental health progress note (this template) |
First visit with a new client | |
Medication management visit | |
Session in a group program | |
Client in crisis or new risk disclosed | |
Session structured by a payer's format | DAP or BIRP, with the same clinical content |
The sections, and what reviewers look for in each
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|---|
| Name or ID, date, start and stop time, modality, client location if telehealth | That time supports the code billed |
| Working diagnosis with its ICD-10-CM code | That it matches the treatment plan |
| Appearance, behavior, mood and affect, thought process and content, orientation | That it changes when the client does |
| What you screened for, the answers, your judgment | That it's present every session |
| Report since last session, measure scores with dates | |
Interventions and response | What you did, by name, and how the client engaged | Named techniques that match the treatment plan |
| Each treatment plan goal, with evidence | Medical necessity for continuing |
| Next session, homework, coordination, signed and dated | |
For a structured mental status section, the mental status exam checklist has the full list of domains.
Mental health progress note example
Tomas is a fictional 42‑year‑old accountant in his sixth session of CBT for generalized anxiety disorder (F41.1). His GAD‑7 was 15 at intake. The scale runs from 0 to 21. All details are invented.
Client and session: Tomas R. October 22, 2026, 10:05 to 10:56 am. Telehealth by video, client at his office with the door closed, in the same state as the clinician.
Diagnosis: Generalized anxiety disorder, F41.1.
Mental status: Dressed for work, well groomed. Fidgeting with a pen early in the session, settled after 15 minutes. Speech normal rate. Mood "wound up, but less than before." Affect anxious, appropriate to content. Thought process goal‑directed. Thought content focused on a quarterly deadline, no obsessions or perceptual disturbance reported. Alert and oriented.
Risk: Asked about thoughts of death, suicide and self‑harm. Denies all. Drinks two glasses of wine most evenings to "turn my brain off," unchanged from intake. Risk judged low.
Symptoms and measures: Reports worry time practice on four of seven days. Still checks work email after 10 pm most nights. Sleep onset about 40 minutes, down from over an hour. GAD‑7 today: 9.
Interventions and response: Reviewed the worry log and sorted the week's worries into ones he could act on and ones he couldn't. Introduced a decatastrophizing worksheet for the deadline worry. Tomas rated the worst case as 70% likely at the start and 25% likely after working through the evidence. He laughed when he said the same deadline had been met for eleven straight quarters.
Progress toward goals: Goal 1, reduce GAD‑7 below 10: met for the first time today. Goal 2, sleep onset under 30 minutes: improving, not met. Goal 3, reduce evening drinking to two nights a week: not started; client wants to address it after the deadline.
Plan: Weekly sessions to continue. Worry time daily, plus one decatastrophizing worksheet. Email off by 9 pm on three nights. Revisit the drinking goal at session 8. Repeat GAD‑7 next session.
Signature: Electronically signed by the treating clinician, with credentials, October 22, 2026, 11:20 am.
A coding detail worth knowing if you inherit old records: in the FY2027 tabular list, F41.1 also covers the older terms anxiety neurosis, anxiety reaction, anxiety state and overanxious disorder. A referral letter that uses one of them still points to the same code.
Blank mental health progress note template
To make a PDF, paste the headings into a word processor and export. If you build a fillable PDF, lock it after signing; changes after that belong in a dated addendum.
Client and session: Name or ID. Date. Start time. Stop time. In person or telehealth. Client location.
Diagnosis: Name and ICD‑10‑CM code.
Mental status: Appearance. Behavior. Speech. Mood (client's words) and affect. Thought process. Thought content. Perception. Orientation. Insight and judgment.
Risk: Suicidal thoughts. Self‑harm. Harm to others. Substance use. Your judgment and any safety steps.
Symptoms and measures: Since last session. Measure name, score, date.
Interventions and response: Technique used. Client's engagement and response.
Progress toward goals: Goal 1. Goal 2. Goal 3. Met, partly met, not met, with evidence.
Plan: Next session. Homework. Coordination or referrals. Treatment plan changes.
Signature: Name, credentials, date signed.
Signatures: the detail that fails audits
An unsigned note isn't a finished record. For Medicare, CMS requires services to be authenticated by the author with a handwritten or electronic signature. Stamped signatures are not typically acceptable, with an exception for a clinician whose disability prevents signing (Medicare Program Integrity Manual, chapter 3, section 3.3.2.4).
Sign each note yourself, include your credentials, and let the EHR record the date and time. If you supervise a pre‑licensed clinician, check what your state board and the payer require from each of you on the note.
Common mistakes in mental health progress notes
- A mental status section copied from the last session. If the client looked different, the note should too.
- A measure given but never mentioned again. If you scored a GAD-7 or PHQ-9, compare it with the last one in the note.
- Risk documented only when something comes up. Write what you asked and what the client said every time.
- Goals that never appear in the note. A reviewer deciding whether therapy is still needed looks for progress against the plan.
- Leaving out where a telehealth client was. The client's location affects licensure and, for some payers, the place of service on the claim.
Progress notes and HIPAA
This note is part of the client's record. HIPAA's definition of psychotherapy notes leaves out exactly what this template holds, such as start and stop times, test results and summaries of diagnosis, symptoms and progress (45 CFR 164.501). Our article on psychotherapy notes explains what can be kept separately.
How Twofold writes mental health progress notes
Record the session in Twofold and choose a progress note format from the Template menu. The draft comes back with the sections filled from what was said, and you check the mental status and risk lines before signing. The University guide on writing therapy progress notes in DAP, BIRP or GIRP walks through it, and AI therapy notes covers the product.
Progress notes template, behavioral health progress note template, psychotherapy progress note template, treatment plan template and mental status exam checklist.
Reviewed and updated October 2026.
