What a progress note template is for
A progress notes template gives every session note the same skeleton, so you don't have to remember the required pieces at the end of a long day. Any reader, from a covering clinician to an auditor, can then find the same information in the same place in every note.
"Progress note" describes what the note is for. SOAP, DAP and BIRP are layouts for it. The template on this page is format‑neutral: it lists the elements a mental health progress note should contain whichever headings you use, and you can rearrange them into your preferred format.
| | |
|---|
Narrative (this template) | Freedom to order the note around the session | Easy to drift into story and skip the plan |
| Client report and clinician observation kept apart | Medical templates assume vital signs |
| The shortest of the structured formats | No dedicated place to name your intervention |
| Intervention and response each get a heading | Behavior is sometimes read as observed behavior only |
| Starts from the treatment plan goal | Weak if the treatment plan goals are vague |
If an agency, insurer or supervisor specifies a format, that settles it. Otherwise, choose the one that matches how you think about a session, and stick with it for every client so your notes are comparable over time.
What every mental health progress note should include
- Date, session start and stop times, and whether it was in person or telehealth (with the client's location for telehealth).
- Who attended, for family or couples sessions.
- The diagnosis being treated.
- Symptoms and functioning since the last session, including any scores from standardized measures.
- The interventions you used, named specifically.
- How the client responded.
- Progress toward the goals in the treatment plan.
- Risk: what you asked about and what you found.
- The plan, including the next appointment.
Most of that list lines up with what HIPAA says a psychotherapy note is not. The federal definition excludes session start and stop times, modalities and frequency of treatment, test results, and any summary of diagnosis, functional status, treatment plan, symptoms, prognosis and progress (45 CFR 164.501). Those items belong in the progress note.
Mental health progress note example
The client here is fictional. Jordan, 29, is in treatment for post‑traumatic stress disorder, chronic (F43.12), after a highway collision 14 months ago. This is session 9 of cognitive processing therapy.
Session details: October 6, 2026, 2:02 to 2:55 p.m., telehealth (video), client at home in the same state. Individual session.
Since last session: Jordan drove on the highway for one exit with his partner in the passenger seat, the first time since the collision. He reports two nightmares this week, down from five. PCL‑5 today is 38, compared with 52 at intake.
Interventions: Reviewed his worksheet on the stuck point "I should have seen the truck coming." Used Socratic questioning about what he could have known in the two seconds before impact. Assigned a new worksheet on safety beliefs.
Response: Jordan was able to name two facts that contradict the stuck point and rated his belief in it at 40%, down from 85% at the start of treatment. He became tearful when describing the moment of impact and recovered within a few minutes using paced breathing.
Risk: Asked about suicidal thoughts and alcohol use. Denies both. No change from the prior assessment.
Progress toward goals: Goal 1 (drive on the highway independently) partly met. Goal 2 (fewer than two nightmares a week) not yet met, trend improving.
Plan: Session 10 next week, same time. Two highway exits with his partner before then. Repeat PCL‑5 at session 12.
Blank progress notes template
Copy this into your EHR or a document. If you need a PDF, paste it into any word processor and save or export it as PDF; the headings carry over.
Client name or ID: Date: Start time: Stop time: Location: in person / telehealth (client location). Participants:
Diagnosis treated: name and ICD‑10 code.
Since last session: symptoms, events, functioning, homework, measure scores with dates.
Interventions: the specific techniques or modalities used today.
Response: how the client engaged and what changed during the session.
Risk: what was screened, the client's answers, your judgment, and any safety steps.
Progress toward treatment plan goals: one line per goal: met, partly met, not met, with the evidence.
Plan: next appointment, homework, coordination, changes to the treatment plan.
Clinician signature, credentials and date signed:
Adding EMDR or psychiatric details
For an EMDR session, add the target memory, the phase you worked in, and the client's SUD and VOC ratings at the start and end of processing. Our EMDR note templates have that layout ready.
A psychiatric progress note for a medication visit needs current medications, adherence, side effects, any labs, and the prescribing decision. The psychiatric SOAP note template is built for that visit rather than this one.
Progress notes versus psychotherapy notes
This is the HIPAA distinction that matters most for therapists. Progress notes are part of the client's designated record set, so clients have a right to access them. Psychotherapy notes are listed as an exception to that right of access (45 CFR 164.524), and most disclosures of them need the client's written authorization (45 CFR 164.508).
The protection only applies when psychotherapy notes are kept apart from the rest of the record. If your process reflections sit inside the progress note, they are progress note content. Write the progress note on the assumption that the client may read it one day. Our article on psychotherapy notes covers what to keep separate.
Common progress note mistakes
- Leaving out start and stop times. Psychotherapy codes such as 90832 and 90837 are chosen by time, and the note has to back up the code billed.
- Naming the intervention as "supportive therapy" or "processed feelings." Write what you actually did.
- Notes that never mention the treatment plan. A reviewer should see each session move a goal forward or explain why it didn't.
- Cloned notes. Identical wording session after session hides what actually changed, and it reads as copied to anyone reviewing the chart.
- Signing days later. Write the note as close to the session as you can and date the signature honestly.
CPT is a registered trademark of the American Medical Association. CPT codes copyright 2026 American Medical Association. All rights reserved.
How Twofold writes progress notes
In Twofold, choose Progress (Mental Health) in the Template menu, or DAP, BIRP or GIRP if you prefer a structured format, then record the session. The draft is ready for you to review and edit before you copy it into your EHR. Our University guide on writing therapy progress notes in DAP, BIRP or GIRP shows each step, and AI therapy notes covers the product in general. For background on the note type itself, see our article on progress notes.
Mental health progress note template, psychotherapy progress note template, SOAP note template, DAP note template, BIRP note template and treatment plan template.
Reviewed and updated October 2026.
