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Client Progress Notes Template

A structured format a therapist uses to document mood, progress, and interventions from each session with a client.

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Client Name:*

Nombre

Apellido

Session Date:*

Type of Session:

Service Code:

Section

Client Presentation:

Affect:

Mood:

Interpersonal:

Functional Status:

Assessment and Observations:

Section

Safety Issues:

Suicidal Ideation Self-Harm Harm to Others None

Client has:

Improved Stayed the Same Declined

Describe Medical Issues:

Medication Issues:

None Side Effects Non-Compliance Needs Review

Explain:

Section

Subjective Report:

Feeling Better Feeling Worse No Change New Concerns

Observations:

Engaged Distracted Tearful Calm

Comments:

Section

Interventions:

CBT Mindfulness Psychoeducation Role-Play

Homework:

Section

Objective 1:

Progress:

Objective 2:

Progress:

Objective 3:

Progress:

Notes:

Recommendations:

Continue Current Plan Adjust Treatment Plan Refer Out Discharge

New treatment goals/approach:

New Treatment Frequency:

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