Clinical documentation guide

Therapy Progress Note Template

A therapy progress note documents the clinically relevant facts of an encounter, the treatment delivered, the client’s response, progress toward goals, and the next plan. It can be organized as SOAP, DAP, BIRP, GIRP, or a custom structure required by a setting or payer.

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Best for

  • Clinicians whose organization uses a custom progress-note format
  • Notes that need an explicit goal-progress statement
  • Teams creating a consistent documentation checklist across formats

What makes this format different

This flexible format is organized by documentation function instead of a specific acronym. Use it when your setting defines required elements but does not mandate SOAP, DAP, BIRP, or GIRP.

Copy and adapt

Blank Progress note template

Session focus and clinical data
[Client report, relevant observations, symptoms, functioning, and session focus.]

Interventions
[Specific therapeutic interventions connected to treatment goals.]

Response and progress
[Client response, engagement, change, barriers, and progress toward goals.]

Risk and safety
[Risk findings assessed today, protective factors, actions taken, or “not assessed” when appropriate.]

Plan
[Next steps, frequency, homework, referrals, coordination, and next-session focus.]

Adapt required fields to your license, setting, payer, EHR, jurisdiction, and organization policy. Do not use a generic template as a compliance checklist.

Prompt architecture

How to write each section prompt

A useful section prompt tells the writer what evidence belongs in the section, where the information comes from, and what must not be inferred. The prompts below are adapted from BeeThere’s production note-format definitions.

1

Session focus and clinical data

Establish why the encounter mattered clinically.

Section prompt

Summarize the client’s relevant report, observable presentation, symptoms, functioning, and the session focus. Clearly attribute reported information and keep unrelated narrative out.

Include

  • Presenting issue
  • Change since prior session
  • Functional impact

Guardrail

Avoid documenting sensitive detail that is not necessary for treatment or continuity of care.

Fictional section example

The client reported lower mood on four days this week after a schedule change and missed one class. They were fully oriented, spoke softly, and identified isolation as the session focus.

2

Interventions

Document the skilled service provided.

Section prompt

Name the therapeutic interventions, psychoeducation, assessment, or skill practice completed and explain how each addressed a treatment goal.

Include

  • Specific technique
  • Clinical purpose
  • Any structured assessment

Guardrail

Avoid a list of modality names without describing what occurred.

Fictional section example

The therapist used behavioral activation to identify two values-aligned activities and collaborative problem solving to address the changed schedule.

3

Response and progress

Record response to care and movement toward the treatment plan.

Section prompt

Describe participation, insight, response to interventions, measurable change, barriers, and progress or lack of progress toward the relevant treatment goal.

Include

  • Immediate response
  • Goal progress
  • Barrier or strength

Guardrail

Do not force a positive-progress statement when the record supports no change or worsening.

Fictional section example

The client generated two feasible activities and rated confidence at 7/10. Mood symptoms remain elevated, but willingness to re-engage socially represents partial progress toward the activation goal.

4

Risk and safety

Document risk only to the level actually assessed and clinically relevant.

Section prompt

Record current or historical risk findings assessed during the encounter, relevant protective factors, overall clinical risk, and actions taken. If risk was not assessed in this encounter, do not invent findings.

Include

  • Finding
  • Protective factors when assessed
  • Action or rationale

Guardrail

Never auto-populate “denies SI/HI” unless the clinician actually assessed it.

Fictional section example

The client denied current suicidal ideation when asked and identified a supportive sibling and future school plans as protective factors. No acute safety intervention was indicated.

5

Plan

Create continuity between this encounter and the next.

Section prompt

Document treatment frequency, next interventions, between-session practice, referrals or coordination, and the next-session focus.

Include

  • Timing
  • Client and clinician actions
  • Next focus

Guardrail

Avoid a plan disconnected from the documented goal and response.

Fictional section example

Continue weekly therapy. The client will complete one social and one mastery activity before the next visit. Reassess mood, attendance, and activation barriers.

Fully fictional

Completed Progress note example

This fictional example illustrates a flexible progress note for an outpatient session focused on low mood and behavioral activation.

Session focus and clinical data

The client reported lower mood on four days this week after a schedule change and missed one class. They were fully oriented, spoke softly, and identified isolation as the session focus.

Interventions

The therapist used behavioral activation to identify two values-aligned activities and collaborative problem solving to address the changed schedule.

Response and progress

The client generated two feasible activities and rated confidence at 7/10. Mood symptoms remain elevated, but willingness to re-engage socially represents partial progress toward the activation goal.

Risk and safety

The client denied current suicidal ideation when asked and identified a supportive sibling and future school plans as protective factors. No acute safety intervention was indicated.

Plan

Continue weekly therapy. The client will complete one social and one mastery activity before the next visit. Reassess mood, attendance, and activation barriers.

Quality check

Common documentation mistakes

  • Confusing a progress note with separate psychotherapy/process notes
  • Recording excessive conversation detail instead of clinical relevance
  • Omitting the intervention or client response
  • Claiming progress without tying it to a treatment goal
  • Auto-populating a risk statement that was not assessed

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