Client Progress Notes Template
Client Name:
*
First Name
Last Name
Session Date:
*
-
Month
-
Day
Year
Date
Type of Session:
Please Select
Individual
Couples
Family
Group
Service Code:
Please Select
90837: Psychotherapy, 60 min
90808: Psychotherapy, 75 min
90834: Psychotherapy, 45 min
90853: Group Therapy
Presentation Assessment
Client Presentation:
Please Select
Oriented/Alert
Disorganized
Tangential
Preoccupied
Circumstantial
Not Assessed
Affect:
Please Select
Appropriate
Inappropriate
Labile
Constricted
Blunted
flat
Not Assessed
Mood:
Please Select
Euthymic
Depressed
Dysphoric
Anxious
Angry
Euphoric
Stable
Not Assessed
Interpersonal:
Please Select
Interactive
Hyperverbose
Guarded
Withdrawn
Hostile
Functional Status:
Please Select
Intact
Impaired
Progressing
Digressing
Variably Impaired
Not Assessed
Assessment and Observations:
Safety & Medical Issues
Safety Issues:
None
Suicidal Ideation
Homicidal Ideation
Other
Client has:
Intent to act
Plan to act
Means to act
Describe Medical Issues:
Medication Issues:
Yes
No
Explain:
Subjective / Objective
Subjective Report:
Feels depressed
Feeling anxious
Lack of motivation
Sleeping too little
Sleeping too much
Issues with partner
Feels overwhelmed
Feels directionless
Feels better overall
Feels worse overall
Issues at work
Issues at home
Parenting issues
Feels stressed
Less conflict
Improved Intimacy
Decreased intimacy
Improved communication
Fighting less
Communication worse
Maintaining progress
Still feels stuck
Communication same
Mood swings
Mood swings better
Mood swings worse
Anxiety decreasing
feels self-conscious
Anger issues
Feeling grief and loss
Lack of focus/organiz.
Sleep is better
Getting more exercise
Feels more secure
More self-confident
Increase in motivation
Defeating self-talk
De-escalating fights
Increased understanding of partner
Better work/home balance
Better self-care
Difficulty breaking patterns
Other
Observations:
Seems depressed
Seems anxious
Lack of motivation
Sleeping too much
Issues with partner
Seems overwhelmed
Seems better overall
Seems worse overall
Seems stressed
Improved intimacy
Decreased intimacy
Communicat. improved
Fighting increased
Fighting less
Communication worse
Maintaining progress
Mood swings better
Mood swings worse
Anxiety decreasing
Seems self-conscious
Anger issues
Moving through grief
Lack of focus/organiz.
Seems more secure
More self-confident
Increase in motivation
Defeating self-talk
Better self-care
Committed to therapy
Increased understanding of partner
Better work/leisure balance
Becoming isolated
Continues to blame others
Taking more responsibility for emotions
More awareness of internal dialog
Breaking self-defeating patterns
Difficulty breaking patterns
Establishing better boundaries
Other
Comments:
Interventions
Interventions:
Cognitive Challenging
Cognitive Refocusing
Cognitive Reframing
Communication Skills
Compliance Issues
Expl. Relationship Ptrn
Expl. Coping Patterns
Explore Emotions
Guided Imagery
Interactive Feedback
Interpersonal Res.
Mindfulness Training
Preventative Services
Psycho-education
Relaxation Techniques
Review of Progress
Role Play
Problem Solving
Supportive Reflection
Symptom Mgt
Somatic Exercises
EMDR
Active Imagination
Dream Exploration
DBT
Mirroring
Homework
Other
Homework:
Objectives & Progress
Objective 1:
Progress:
Please Select
Improved
Progressing
Maintained
No progress
Regressed
Variable
Not addressed
Objective 2:
Progress:
Please Select
Improved
Progressing
Maintained
No progress
Regressed
Variable
Not addressed
Objective 3:
Progress:
Please Select
Improved
Progressing
Maintained
No progress
Regressed
Variable
Not addressed
Notes:
Recommendations:
Continue Therapeutic Focus
Change Treatment Goals / Objectives
Increase Frequency of Sessions
Decrease Frequency of Sessions
Terminate Treatment
Other
New treatment goals/approach:
New Treatment Frequency:
Please Select
Weekly
Twice per week
Every 2 weeks
As needed
Submit
Should be Empty: