As a mental health professional, you understand the importance of keeping clear and organized records. Mental health progress notes are the foundation of effective therapy, helping you document sessions, track client progress, and ensure continuity of care. Progress notes aren’t just about meeting documentation requirements—they are essential for demonstrating accountability, monitoring treatment effectiveness, and ensuring compliance with legal and ethical standards. Research from 2023 indicates that collaborative documentation, where clinicians and patients jointly write visit notes, leads to a significant positive shift toward person-centered care. This approach enhances the integration of patient perspectives within clinical notes.
Beyond improving client care, progress notes also facilitate communication with other healthcare providers. By keeping your documentation thorough and precise, you ensure everyone involved in your client’s journey has the necessary context to provide the best support. In this guide, you’ll learn how to write progress notes for mental health, explore practical templates, and discover tips for streamlining your documentation process. By the end, you’ll have the tools and strategies you need to make progress notes writing an efficient and impactful part of your practice.
What Are Mental Health Progress Notes and Why Are They Important?
Progress notes are the critical piece of documentation you, as a mental health therapist, should write after each session with your client. These notes serve as a systematic way to capture essential information about your client’s condition, progress, and treatment plans. By providing a structured format, progress notes ensure continuity of care, track therapeutic outcomes, and demonstrate accountability in mental health care.
The specific details of a progress note can vary depending on your state, local regulations, and workplace policies. However, as a mental health therapist, you likely write progress notes after each session to document:
- The treatment methods you used (like mindfulness techniques, stress management strategies, or cognitive restructuring).
- How your client responded to the session.
- Any major changes since their last visit.
These notes also play a critical role in tracking client progress, as they document:
- Client-reported progress toward treatment goals.
- Changes in symptoms or behaviors over time.
- Interventions used during sessions and their effectiveness.
In addition to monitoring progress, well-maintained progress notes support compliance with ethical and legal standards. Insurance providers often require detailed records to approve claims, and accurate documentation ensures your work meets their criteria. Moreover, progress notes enhance collaboration with other healthcare providers by providing a complete picture of the client’s care. By keeping thorough and organized records, you not only improve client outcomes but also demonstrate professionalism and commitment to best practices in mental health care.
How do progress notes differ from psychotherapy notes?
While progress notes and psychotherapy notes may seem similar, their purposes, content, and access protocols are significantly different.
Progress notes are formal, structured records that document session details, client progress, and treatment plans. They serve as a communication tool between therapists, other healthcare providers, and sometimes insurers or family members involved in the client’s care. These notes include medical and treatment plan details and may be required to meet specific insurance documentation standards. They play a critical role in demonstrating the effectiveness of your methods, ensuring continuity of care, and streamlining billing and reimbursement processes.
Psychotherapy notes, on the other hand, are personal reflections meant solely for the therapist’s use. These notes often include unique interpretations, impressions, or hypotheses about a client’s thoughts and behaviors, serving as a guide for future sessions. Unlike progress notes, psychotherapy notes are:
- Protected under HIPAA regulations and generally cannot be shared with anyone, including the client, unless explicit permission is given.
- Kept separate from other documentation such as billing or medical records.
- Free from specific details about medications, clinical test results, diagnoses, treatment plans, or symptoms.
While progress notes provide a formal and comprehensive overview of a client’s therapeutic journey, psychotherapy notes are more flexible and personal, focusing on the therapist’s internal reflections. Both types of documentation serve distinct purposes but are essential for delivering effective mental health care.
What to Include in Progress Notes: 6 Requirements
To create effective progress notes, it’s essential to include specific components that provide a clear and comprehensive picture of your client’s journey. These elements ensure that your documentation meets clinical, ethical, and legal standards while supporting effective care delivery. Below are the six key requirements for mental health progress notes:
1. Session details
Every progress note should start with basic session information to establish a clear record. This includes:
- Start and stop times of the session.
- The location of the session (e.g., telehealth or in-person). For telehealth, specify the client’s location (e.g., “home” or “office”) and confirm that a HIPAA-compliant platform was used.
- The date of service.
- The client’s name and a second unique identifier, such as their date of birth or an assigned ID number.
- The provider’s name, credentials, and contact details.
2. Person-centered details
Your progress notes should capture client-specific details that reflect their unique mental state and experiences. Include:
- Statements made by the client in their own words to provide context and authenticity.
- Observations that describe the client’s feelings, behaviors, or reactions during the session.
Example: “The client stated, ‘I feel overwhelmed by work deadlines,’ and appeared visibly tense.”
3. Patient-centered observations
Document your clinical assessment of the client’s current mental state to provide a complete picture of their condition. Include at least three components of the mental status exam, such as:
- Appearance (e.g., neat, disheveled).
- Behavior (e.g., restless, cooperative).
- Mood or affect (e.g., anxious, flat).
- Reasoning or thought patterns (e.g., logical, disorganized).
Example: “The client appeared fatigued, was mildly irritable, and demonstrated difficulty concentrating.”
4. Progress toward goal(s)
One of the most critical aspects of progress notes is tracking the client’s progress against their treatment goals. Be sure to:
- Identify whether the client made progress, regressed, or remained stable.
- Note any updates to the treatment plan, including changes in goals or strategies.
Example: “The client reported moderate progress in managing social anxiety, although group settings remain a challenge.”
5. Risk assessment
Thoroughly document any risks discussed or identified during the session, such as suicidal ideation (e.g., thoughts of self-harm with specific plans), harm to others (e.g., violent intentions or triggers), or substance abuse (e.g., frequent alcohol or drug use). Other risks may include environmental factors like unstable living conditions or domestic violence, and non-compliance with treatment such as refusing medication or missing sessions.
- If risks are identified, specify the risk level (low, moderate, or high) and document any safety plans created. For example, “The client reported moderate suicidal ideation without a specific plan. A safety plan was created, which included removing access to harmful items, scheduling a follow-up session within 48 hours, and providing a 24/7 crisis hotline.
Example: A safety plan was created to address the risk of moderate suicidal ideation and was reviewed with the client, who agreed to its implementation.
6. Clinical path forward
Conclude your progress notes by outlining the strategies and practices discussed for the client’s future care. This could include:
- Evidence-based practices used during the session.
- Skills or techniques for the client to practice before the next session.
- Adjustments to the treatment plan.
Example: “The client was introduced to mindfulness exercises and will practice these techniques daily to manage stress. Progress will be reviewed in the next session.”
How to Write Mental Health Progress Notes
As a therapist, writing clear and comprehensive mental health progress notes is essential for delivering high-quality care and ensuring compliance with professional standards. These notes not only help you track your client’s progress but also provide a detailed record that supports treatment planning and legal requirements. Below is a step-by-step guide to crafting effective progress notes, complete with examples tailored for your practice.
1. Note header
Start with essential session details to ensure proper identification and context. This section provides a quick overview of the session’s logistics.
Include:
- Client’s name and a second unique identifier (e.g., date of birth or ID number).
- Date and time of the session.
- Session duration.
- Service codes (if applicable).
2. Diagnosis
Document the client’s current diagnosis using ICD-10 or DSM-5 codes. This aligns your notes with the treatment plan and provides a reference for clinical decisions.
Example:
- Diagnosis: Generalized Anxiety Disorder (F41.1)
3. Patient presentation
Describe the client’s appearance, behavior, and emotional state during the session. This section captures observable factors that might influence the session or reflect changes in the client’s condition.
Example:
- The client appeared well-groomed but exhibited restlessness, avoided eye contact, and spoke in a subdued tone when discussing stressors.
4. Safety issues
If there are concerns about the client’s safety, document them thoroughly, including any risk assessments or safety plans. Even if no risks are present, include a statement confirming this.
Example:
- The client denied suicidal ideation or self-harm. No immediate safety concerns were identified.
5. Medications
If you’re a prescribing clinician, record details about the client’s medication regimen, adherence, and any reported side effects.
Example:
- Medication: Escitalopram 10 mg daily. The client reports taking it regularly with no side effects.
6. Symptom description and subjective report
Capture the client’s self-reported symptoms, feelings, and experiences. Including direct quotes provides authenticity and reflects the client’s perspective.
Example:
- The client stated, “I feel like I’m always on edge,” and reported difficulty concentrating at work due to excessive worry.
7. Relevant content
Include objective information that supports the session, such as test results, external documents, or key observations.
Example:
- Administered GAD-7 assessment. Score: 15 (moderate anxiety). Results were reviewed and discussed with the client.
8. Interventions used
Detail the therapeutic techniques or interventions applied during the session. Be specific about their purpose and how they address the client’s goals.
Example:
- Intervention: Introduced progressive muscle relaxation as a stress management tool and provided psychoeducation on anxiety triggers.
9. Treatment plan progress
Discuss the client’s progress toward their treatment goals. Note whether objectives are being met or need adjustment, and outline plans for the next steps.
Example:
- The client demonstrated improved coping skills but continues to struggle with public speaking anxiety. Plan to incorporate exposure therapy in future sessions.
10. Signatures
Authenticate your notes with an electronic or physical signature, ensuring compliance with HIPAA standards.
Example:
- Signed by: Jane Smith, LCSW
- Date: January 15, 2025
Client progress notes example
Clinician Name: | Agency Name: | Address: |
Jane Smith, LCSW | Wellness Therapy Center | 1234 Therapy Lane, Suite 101, Cityville, ST 12345 |
Client Name: | John Doe | Date: | 03/01/2025 |
Client DOB | 01/02/1980 | Start Time: | 3.00 PM |
Diagnosis | F41.1, Generalized Anxiety Disorder | End Time: | 3.50 PM |
Client’s subjective concerns/chief complaint
“The constant worry is exhausting me. I can’t concentrate at work or relax at home.” The client reported feeling anxious throughout the day, experiencing restlessness, difficulty focusing, and irritability. |
Clinical observations
The client appeared well-groomed but exhibited signs of restlessness, including fidgeting and tapping fingers during the session. Speech was coherent but slightly rushed when discussing stressors. Affect was congruent with reported anxiety. The client denied suicidal ideation or any immediate safety concerns. |
Issues and stressors discussed/session description
The client discussed challenges at work, particularly managing deadlines, which have exacerbated their anxiety. The client also noted strained communication with their partner, further contributing to feelings of frustration. Sleep patterns remain disrupted, averaging 5–6 hours per night, which the client acknowledged negatively impacts their energy levels and mood. |
Interventions/methods provided
Discussed cognitive-behavioral techniques for managing workplace stress.Introduced deep breathing exercises and practiced during the session.Provided psychoeducation on the impact of sleep hygiene on anxiety.Reviewed coping strategies, including setting boundaries and scheduling breaks at work. |
Assessment
The client’s symptoms remain consistent with generalized anxiety but are heightened by external stressors, particularly work deadlines and sleep disruption. No suicidal ideation was present. The client demonstrated motivation to address sleep hygiene and stress management, indicating a positive outlook toward improvement. |
Plan
The client will begin a nightly routine to improve sleep, turning off screens an hour before bedtime.Practice deep breathing exercises twice daily to reduce anxiety symptoms.Monitor workplace stressors and use coping strategies discussed during the session.If symptoms persist or worsen, the client will contact their psychiatrist for further evaluation. |
Next Appointment: 03/08/2025 Clinician Signature: _______________
Downloadable template
Streamline your documentation process with our professionally designed progress notes template. Download a Progress Notes Template: [Click here to download the template]
Mental Health Progress Notes: Templates & Examples
As a therapist, choosing the right format for your mental health progress notes can make your documentation more efficient and effective. Widely used formats like SOAP, DAP, and BIRP provide structured templates that ensure all essential details are included while catering to different documentation styles. Below, we explore each format, its benefits, and how it can align with your practice, along with examples and downloadable templates.
1. SOAP (Subjective, Objective, Assessment, Plan)
SOAP notes are one of the most commonly used formats in mental health care. They offer a clear structure that helps you organize client information into four distinct sections, making it easier to track progress and share information with other professionals.
SOAP is an acronym that stands for:
- Subjective: The client reports feeling anxious and irritable, particularly in social situations.
- Objective: Observed restlessness, avoidance of eye contact, and a rapid heart rate during discussions about stressors.
- Assessment: Symptoms suggest an anxiety flare-up likely triggered by recent life changes.
- Plan: Introduce mindfulness techniques to manage anxiety; consider a medication review if symptoms persist.
When to choose SOAP notes:
SOAP notes are perfect if you want a concise and structured format that highlights both subjective and objective data. They are especially useful if you frequently collaborate with other healthcare providers or need to meet insurance documentation requirements.
Download a SOAP Notes Template

Read: Understanding SOAP Note Format with Tips and Examples
2. DAP (Data, Assessment, Plan)
DAP notes simplify the documentation process by focusing on three key areas: what the client reported, your clinical interpretation, and the planned next steps. This format provides flexibility while ensuring all critical details are captured.
DAP is an acronym that stands for:
- Data: The client reports difficulty sleeping and feeling overwhelmed due to increased workplace stress.
- Assessment: Symptoms indicate heightened stress and potential signs of a depressive episode.
- Plan: Discuss stress management techniques and consider adjusting the treatment plan to incorporate cognitive-behavioral therapy.
When to choose DAP notes:
DAP notes are ideal if you prefer a format that allows for subjectivity while remaining structured. They work well when documenting emotional and behavioral nuances in client interactions.
Download a DAP Notes Template

Read: What are DAP Notes: Tips to Effectively Write Them
3. BIRP (Behavior, Intervention, Response, Plan)
BIRP notes focus on tracking client behaviors, the interventions you used, their responses, and your plans for future sessions. This format is particularly helpful for highlighting the effectiveness of specific therapeutic techniques.
BIRP is an acronym that stands for:
- Behavior: The client expressed frustration, speaking loudly and pacing while discussing workplace stressors.
- Intervention: Guided the client through grounding techniques and explored their triggers.
- Response: The client reported feeling calmer after using grounding techniques and expressed interest in learning additional strategies.
- Plan: Practice grounding techniques daily and review progress in the next session.
When to choose BIRP notes:
BIRP notes are great for documenting how clients respond to interventions during sessions. If your practice focuses on tracking measurable behavioral outcomes, this format may be the most suitable.
Download a BIRP Notes Template

How Simply.Coach streamlines Your progress notes
As a therapist, using the right tools for managing mental health progress notes can save time, reduce administrative tasks, and enhance the quality of your documentation. A HIPAA-compliant therapy practice management platform like Simply.Coach provides features that streamline your workflow, ensure compliance, and keep your notes secure. Here’s how these tools can help:
- Simplify documentation with note-taking features: Simply.Coach streamline your workflow with intuitive note-taking features. You can create customized notes for each session, link them directly to client records, and quickly access past notes with searchable archives. These tools ensure efficient, accurate documentation without the hassle of repetitive tasks.
- Set reminders for timely note-taking: Avoid delays in documentation with automated reminders and notifications. These tools help you complete notes promptly after sessions, ensuring details are fresh and accurate.
- Ensure secure, HIPAA-compliant storage: Protect client confidentiality with encrypted storage, access controls, and audit trails. Simply.Coach ensures that your data is safe and compliant with all regulatory standards.
- Integrate with your workflow: Enhance efficiency with features like calendar sync for scheduling, client portals for secure collaboration, and digital signatures for authenticated documentation.
Why choose Simply.Coach?
Simply.Coach is more than just a tool for managing progress notes—it’s an all-in-one therapy management platform designed specifically for therapists. With features like pre-built templates, automated reminders, and secure HIPAA-compliant storage, Simply.Coach empowers you to focus on delivering exceptional care while minimizing administrative tasks.
Accurate and structured progress notes are essential for improving client outcomes, ensuring continuity of care, and maintaining compliance with professional standards. Simply.Coach simplifies your workflow with intuitive note-taking features, secure storage, and seamless integration with your daily practice. These tools empower you to document effectively, save time, and provide the best possible support to your clients. Take your practice to the next level with Simply.Coach. Book a demo today or start a 14 days free trial and experience seamless documentation firsthand.
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About Simply.Coach
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