Therapy progress note templates provide mental health professionals with standardized frameworks for documenting client sessions efficiently and comprehensively. 

Therapy progress notes should document interventions, client responses, and treatment progress while meeting regulatory requirements. Well-designed templates strike a balance between thoroughness and efficiency, allowing clinicians to focus more on client care and less on administrative documentation. 

This article covers essential elements, implementation strategies, and best practices for therapy progress note templates to help mental health professionals optimize their clinical documentation processes.

What Is a Therapy Progress Note Template?

A therapy progress note template is a standardized format or framework used by mental health professionals to document client sessions, interventions, observations, and treatment progress. These templates provide a consistent structure for recording essential clinical information, ensuring that important elements are captured systematically across all client interactions.

Who Can Use Therapy Progress Note Templates?

Therapy progress note templates serve various mental health professionals across various practice contexts. 

• Psychologists utilize these templates for individual, group, and assessment sessions, while licensed professional counselors implement them in outpatient therapy services. 

• Clinical social workers employ progress note templates across diverse practice settings from hospitals to community centers.

• Marriage and family therapists benefit from structured documentation for couples and family sessions, and psychiatrists use templates to document both medication management and psychotherapy interventions. Psychiatric nurse practitioners integrate these templates into their comprehensive mental health care documentation approach.

• Substance use counselors rely on structured progress notes for addiction treatment documentation, while school counselors adapt templates for student counseling sessions.  

How to Bill and Code Therapy Progress Notes

Proper billing for therapy services requires accurate CPT code selection and supporting documentation. 

Progress notes must document session duration, medical necessity linked to diagnosis, specific interventions, client response, and goal progress. 

Different insurers have specific requirements—Medicare requires functional impairment documentation, Medicaid focuses on treatment plan alignment, and private insurers follow contract terms. 

Common billing mistakes include upcoding, incomplete documentation, identical notes across clients, and delayed documentation.

Therapy Progress Notes Templates

BIRP Format (Behavior, Intervention, Response, Plan)

The BIRP format provides a comprehensive structure for documenting therapy sessions. The Behavior section captures the client's presentation, mood, and affect, along with verbatim statements, reported experiences, and observable behaviors or symptoms. This section establishes a baseline of the client's state at the time of the session and documents presenting concerns.

• The Intervention component details specific therapeutic techniques employed during the session, skills taught or reviewed, and therapeutic conversations or exercises conducted. This section demonstrates the active treatment provided and connects interventions to treatment plan goals.

• In the Response section, clinicians document the client's reaction to interventions, progress toward established treatment goals, and any insights gained or resistance encountered during the therapeutic process. This critical section demonstrates the effectiveness of interventions and guides future treatment approaches.

• The Plan component outlines the next session's focus, homework assignments for the client, any referrals or consultations needed, and specific follow-up items. This forward-looking section creates continuity between sessions and establishes accountability for both therapist and client.

SOAP Format (Subjective, Objective, Assessment, Plan)

The SOAP format represents one of the most widely used documentation structures across healthcare disciplines, including mental health. 

• The Subjective section captures the client's self-reported symptoms and concerns, their perspective on progress, and direct quotations or narrative information shared during the session. This section preserves the client's voice and personal experience of their condition.

• In the Objective component, therapists document their professional observations, measurable data such as assessment scores or symptom frequency counts, and factual information about the session itself. This section emphasizes observable, verifiable information that supports clinical conclusions.

• The Assessment section contains clinical impressions and interpretations based on the subjective and objective data. It documents progress toward established treatment goals, explores diagnostic considerations, and includes necessary risk assessments. This analytical section demonstrates clinical reasoning and professional judgment.

• The Plan component outlines treatment adjustments based on the current assessment, homework assignments for skill development, the upcoming session's focus areas, and any coordination of care elements with other providers. This action-oriented section creates accountability and direction for ongoing treatment.

DAP Format (Data, Assessment, Plan)

The DAP format offers a streamlined alternative to the SOAP structure, combining elements for greater efficiency. 

• The Data section merges subjective and objective information, documenting session content, clinical observations, client statements, and behavioral presentations. This consolidated approach captures essential information without the rigid separation found in other formats.

• The Assessment component contains the clinician's professional analysis and impressions, evaluation of progress toward treatment goals, and observations about the therapeutic relationship dynamics. This interpretive section connects the documented data to clinical understanding and treatment direction.

• In the Plan section, clinicians outline next steps in treatment, specific tasks for clients to complete between sessions, and future interventions under consideration. This forward-looking component maintains treatment momentum and establishes a clear direction for ongoing therapeutic work.

GIRP Format (Goals, Intervention, Response, Plan)

The GIRP format emphasizes goal-oriented treatment documentation. 

The Goals section identifies specific treatment plan objectives addressed during the session, the client's personal goals for that particular meeting, and target symptoms or behaviors being addressed. This goal-focused approach ensures that each session connects directly to established treatment objectives.

• The Intervention component details therapeutic approaches utilized during the session, specific techniques or activities implemented, and any psychoeducational content delivered to the client. This section demonstrates the active treatment provided and its relevance to identified goals.

• In the Response section, clinicians document the client's engagement with the provided interventions, indicators of progress or setbacks observed, and therapeutic insights gained during the session. This evaluative section assesses intervention effectiveness and client progress.

• The Plan section outlines the next session's focus areas, homework or practice activities assigned to the client, and any adjustments needed to the overall treatment plan. This component maintains treatment continuity and adapts the approach based on observed responses.

Solution-Focused Format

The solution-focused format aligns with brief, strengths-based therapeutic approaches. This documentation style emphasizes client strengths by recording observed and reported positive attributes that can be leveraged in treatment. 

It highlights exceptions to problematic patterns by documenting times when presenting problems are less intense or entirely absent, reinforcing the concept that problems are not omnipresent.

Scaling questions play an important role in this format, recording client self-assessments of progress on a 1-10 scale to quantify subjective improvement. 

The goal work component documents progress toward specific, client-defined goals rather than therapist-imposed objectives. The next steps section outlines small, achievable steps toward desired outcomes, maintaining the incremental, practical focus characteristic of solution-focused therapy.

Progress Note Example: SOAP Note

Below is a sample SOAP note for a therapy session:

Client: Jane Doe
Date of Service: 04/30/2025
Session Time: 1:00pm-1:45pm (45 minutes)
CPT Code: 90834 (Psychotherapy, 45 minutes)
Location: Office/In-person

S (Subjective): Client reports continued anxiety symptoms, stating, "I had two panic attacks this week, but they were less intense than before." Client describes using breathing techniques learned in previous session when feeling anxious at work. Reports improved sleep (6 hours/night vs. previous 4 hours) but continued rumination before bedtime. Denies suicidal ideation, homicidal ideation, or substance use since last session.

O (Objective): Client arrived on time, appropriately dressed and groomed. Affect was anxious at session start but modulated appropriately throughout. Made good eye contact and demonstrated logical, coherent thought processes. Became tearful when discussing workplace stressors but was able to self-regulate using breathing techniques. GAD-7 score: 14 (down from 18 last session), indicating moderate-severe anxiety.

A (Assessment): Client shows early progress in anxiety management through implementation of breathing techniques, as evidenced by reduced panic attack intensity and improved sleep. Workplace stressors continue to be significant anxiety triggers, though client demonstrates increasing insight into anxiety response patterns. Client remains motivated for treatment and is actively practicing skills between sessions. Current diagnosis of Generalized Anxiety Disorder (F41.1) remains appropriate.

P (Plan):

1. Continue weekly individual therapy focusing on cognitive restructuring techniques

2. Introduce progressive muscle relaxation as additional coping strategy

3. Assign daily thought record completion to identify cognitive distortions

4. Collaborate with client's psychiatrist regarding medication management (with signed release)

5. Evaluate effectiveness of sleep hygiene strategies at next session

7 Therapy Progress Notes Requirements

To ensure compliance with legal, ethical, and reimbursement standards, progress notes must meet these seven essential requirements:

1. Timeliness

Timely documentation is fundamental to accurate record-keeping. Mental health professionals should complete progress notes within 24-48 hours of service delivery to ensure maximum recall accuracy. All entries must be dated accurately to establish a reliable chronology of care. The documentation should avoid backdating or predating notes under any circumstances, as this constitutes a serious ethical violation. When documentation occurs on a different date than service delivery, both dates should be clearly documented to maintain transparency.

2. Signature and Authentication

Proper authentication validates the clinical record. Each progress note requires a full professional signature with relevant credentials that establishes professional responsibility for the documented services. When required by specific jurisdictions, appropriate licensure numbers should be included with the signature. 

For clinicians working under supervision, a supervisor's countersignature must be obtained following established supervision protocols. Digital records necessitate appropriate electronic signature protocols that comply with relevant regulations. The signature date must be included to complete proper authentication.

3. Client Identification

Accurate client identification prevents documentation errors. Each page of documentation should include the client's full name and a unique identifier to prevent miscommunication or privacy breaches. Demographic information should be documented consistently across all records to maintain database integrity. For multi-page documents, proper association between all pages and the correct client must be maintained through headers or footers. Including the session number in the treatment sequence helps establish continuity and progression of care.

4. Medical Necessity Documentation

Medical necessity establishes the justification for services. Progress notes should connect clinical services to specific diagnoses or conditions that warrant professional intervention. Documenting functional impairments addressed during the session demonstrates the practical impact of clinical issues. Describing the impact of symptoms on the client's daily life provides context for interventions. The documentation should explain why professional intervention is specifically required for the presenting concerns. Progress notes should demonstrate that services are not provided primarily for convenience but address genuine clinical needs.

5. Intervention Documentation

Detailed intervention documentation demonstrates clinical expertise. Notes should specify evidence-based approaches utilized during the session with sufficient detail to justify the approach. Clinicians should document how specific interventions address diagnosed conditions or symptoms, establishing a clear treatment rationale. Client responses to specific techniques should be described to evaluate intervention effectiveness. Any adjustments made based on client feedback demonstrate responsive clinical care. Including the rationale for selecting particular approaches demonstrates thoughtful clinical decision-making.

6. Goal Progress Tracking

Ongoing progress monitoring demonstrates treatment effectiveness. Progress notes should reference specific treatment plan goals addressed during each session to maintain focused treatment. Measurable progress or barriers encountered should be documented objectively. As treatment evolves, updates to goals should be recorded to reflect changing clinical priorities. Including the client's perspective on progress incorporates their experience into the clinical record. Any revisions to treatment objectives should be noted with appropriate justification.

7. Confidentiality and Privacy Safeguards

Privacy protection maintains ethical practice standards. Progress notes should include only clinically relevant information necessary for treatment purposes. Unnecessary personal details about clients or third parties should be avoided to maintain appropriate boundaries. Informed consent discussions regarding confidentiality limits should be documented to demonstrate ethical practice. 

Any releases of information should be noted in the clinical record to track information sharing. Appropriate access controls should be maintained for all clinical documentation. Any confidentiality or privacy concerns should be addressed immediately with appropriate action. All documentation should follow the minimum necessary standard for information inclusion.

Frequently Asked Questions

How long should a therapy progress note be?

Effective progress notes are typically 1-2 pages in length. They should be comprehensive enough to document essential clinical information but concise enough to be quickly written and reviewed. Focus on quality rather than quantity, ensuring all clinically significant information is captured without unnecessary details.

How can I make progress notes more efficient without sacrificing quality?

Implement structured templates with checkbox elements for common interventions, use clinical shorthand where appropriate, focus documentation on exceptional or clinically significant information, utilize voice-to-text technology, and set aside dedicated documentation time immediately following sessions.

What's the difference between a progress note and a psychotherapy note?

Progress notes are part of the official medical record, documenting services provided, client presentation, and treatment plan progress. Psychotherapy notes (sometimes called "process notes") are clinicians' private notes used for their own process, containing more subjective impressions and hypotheses. Psychotherapy notes receive special privacy protections under HIPAA. 

Bottom Line

Therapy progress note templates support clinical excellence, practice efficiency, and regulatory compliance. When thoughtfully designed and consistently implemented, these templates facilitate comprehensive documentation while minimizing administrative burden. 

The ideal template balances structure with flexibility, ensuring that critical clinical information is captured while preserving the unique voice of each therapist and the individual needs of each client.

Disclaimer

This guide provides general information about therapy progress note templates and does not constitute legal advice. Documentation requirements vary by jurisdiction, profession, practice setting, and payer. Mental health professionals should consult with legal counsel, professional associations, licensing boards, and insurers regarding specific documentation requirements applicable to their practice. Templates should be customized to meet the specific needs of each clinical setting while ensuring compliance with all relevant laws and regulations.