How to Write Psychotherapy Progress Notes

Patricia C., Ph.D.
Clinical Psychologist
notedesigner.com

Sample Progress Notes:

What follows is a sample of psychotherapy progress notes. All of the details are fictional, although based on one or more actual cases. Information about writing a progress note can be found here.

Name: Ms. J. Bond Fee: $75
Date: January 30, 2010 Duration: 50 minutes
Session Note:

Ms B. came 5 minutes late to her appointment explaining that she was anxious to leave the house today. We first addressed some of her fears about leaving the house and how she was able to eventually feel more relaxed through the use of deep breathing exercises.

The client's estimated global assessment of functioning suggests some serious emotional and psychological difficulties and quite serious impairment in relational, work and/or school functioning. The client's affective and emotional state appeared quite depressed and agitated. The client's mental state included a slowing of thought and reduced mental energy. The main themes of the session were: conflict with family members; exploring relational concerns and issues in the workplace; and difficulties with boundaries and self-assertion. The main therapeutic interventions consisted of: an emphasis on here-and-now functioning; a focus on improved problem solving and coping; an emphasis on developing new homework assignments in collaboration with the client; an emphasis on techniques for the development of greater confidence and self-efficacy; and informing the client of how to reach me by telephone between sessions as needed. The client continues to sustain gains made in reduced self-destructive behavior. The recent crisis appears better contained. The ongoing treatment plan includes: addressing problematic coping strategies and mechanisms; building greater social and interpersonal skills; and adjunctive psychiatric/medical assistance. Treatment continues to show good evolution and development. Treatment to continue as indicated.

 

_______________________________
Patricia C., Ph. D.
Clinical Psychologist

 

Name: Mr. Peter Smithish
Date: June 16, 1998
Progress Note:

The patient's estimated global assessment of functioning appeared reasonably good with only short lived and expectable reactions to everyday stressful events. The patient shows only slight difficulty in relational and/or work/school functioning. The patient's affective and emotional state appeared calm and reflective. The patient's mental state included good insight and observing capacity. The main themes of the session were: interpersonal difficulties with spouse/partner; exploration of transgenerational traumas; and exploration of conflicts regarding masculinity and issues of male sexuality. The main therapeutic interventions consisted of: exploration of fantasy life in light of ongoing anxieties; exploration of fears of abandonment and loss as experienced in the transference; and exploration and interpretations of inhibitions regarding pleasure and enjoyment. The patient continues to make good progress with self-understanding and self-insight. Developments continue in the areas of family and relational functioning. The patient demonstrates a capacity for greater enjoyment of leisure time and creative projects. The ongoing treatment plan includes continued support and maintenance of the psychotherapeutic process. Treatment to continue as indicated.

Note that the client described an important dream about the therapy that we linked to his anxieties about trusting that the therapist will remember him after termination of the treatment (something we discussed in our last session). The client expressed that he found this exploration very helpful and comforting.

 

_______________________________
Patricia C., Ph. D.
Clinical Psychologist

 

Name: Jane Doe Fee: $50
Date: September 5, 2013 Duration: 45 minutes
Progress Note:

The patient's affective and emotional state appeared sad and withdrawn. The patient's mental state included improved reflective capacity. The main themes of the session were coping with feelings of rejection in interpersonal relationships, and awareness and exploration of underlying needs for care and support. The main therapeutic interventions consisted of setting goals for the treatment and the session, and the use of role play to help address interpersonal difficulties. Significant gains in self-assertion and positive self-promotion are evident. The ongoing treatment plan includes therapeutic work on building and maintaining self-esteem and self-confidence; and building greater social and interpersonal skills. There are no current outstanding therapeutic issues or concerns. Treatment to continue as indicated.

 

_______________________________
Patricia C., Ph. D.
Clinical Psychologist

Note: Recommendations and examples presented are intended to provide a general overview of how to write psychotherapy progress notes and do not constitute nor can they substitute for legal counsel or official guidelines mandated by any particular professional order or other regulatory body; please be sure to consult and familiarize yourself with the guidelines and rules regarding record keeping in your particular mental health field and/or as stipulated by your profession.

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