How to Write a Basic Therapy Progress Note: A practical guide

Mental health professionals are required to maintain accurate and timely documentation of psychotherapy sessions. Progress notes serve as an official clinical record of each encounter, supporting continuity of care, supervision or consultation, and—where applicable—third-party billing or insurance compliance.

In this guide I outline the key elements of a well-structured progress note, using a format that follows the natural sequence of a session. The structure can be adapted across therapeutic approaches and settings while remaining consistent with documentation standards in the United States, Canada, and many other jurisdictions.

Basic Progress Note Structure

1) Administrative Details

The progress note typically begins with session identifiers:

• Client name
• Date of session
• CPT code (if applicable)
• Diagnostic code
• Session start and end times
• Fee and payment status

Here we are asking ourselves:

💡 What are the key administrative details I need to record?

These administrative details serve as a record of the service provided. Some licensing bodies require the client’s name on every page. Others require time stamps or specific billing codes. It’s always worth checking with your regulatory college or board.

2) Presentation

This first section focuses on how the client arrived to the session both literally and emotionally.

• Session format: Was the session in-person, virtual, or by phone?
• Approach to the session: Was the client engaged, hesitant, enthusiastic, or withdrawn?
• Physical appearance: Without judgment, note any relevant details (e.g., “appeared tired and disheveled”; “arrived with visible injuries”; “dressed casually”).

We might ask ourselves:

💡 How did the client show up today—physically, emotionally, and behaviorally?

The key here is to stay observational, not evaluative. Our clients may one day read their notes. What we write should be both accurate and respectful.

Examples:

• “Client attended in-person and appeared emotionally subdued; greeted therapist quietly and sat with slouched posture.”
• “Session conducted via phone; client sounded tearful and had difficulty speaking at first.”
• “Client arrived punctually, was well-groomed, and appeared more animated than usual.”
• “Client expressed feeling overwhelmed before the session and was hesitant to engage in discussion.”
• “Client presented with high energy and used humor to deflect emotionally charged topics.”

3) State

Next, we capture the client’s emotional, cognitive, and functional state during the session.

Essentially,

💡 What was the client’s emotional and cognitive state during the session?

Emotional and Affective State:

• Reported: What did the client say about how they were feeling?
• Observed: What emotional tone did they convey nonverbally?

Include both negative and positive emotional states where appropriate. Here are some examples:

• “The client reported feeling hopeful following a family visit.”
• “Observed affect was constricted, with long pauses and minimal eye contact.”
• “Client reported feeling ‘numb’ and expressed difficulty connecting with emotions.”
• “Affect appeared congruent with content; some tears when discussing recent family tensions.”
• “Expressed increased sense of calm since last session, reporting, ‘I’m sleeping better and not crying every day anymore.’”

Mental Status:

This can include orientation, thought organization, insight, and memory; as well as cognitive capacity (e.g., tangential thinking, reflective awareness) and risk indicators (e.g., suicidal ideation, dissociation, paranoia) Here are some examples:

• “Thoughts were linear and organized; client demonstrated strong insight into relational patterns.”
• “Client was oriented to time/place/person; attention span appeared limited at times.”
• “Displayed signs of dissociation when describing early trauma.”
• “Speech was pressured and tangential; mood described as ‘edgy.’”

Functional Status

• Global functioning: Estimate the client’s overall psychological and interpersonal functioning. You may use WHODAS or draw from the older GAF scale descriptively.
• Biopsychosocial context: Document key life factors affecting functioning (e.g., job loss, chronic illness, financial strain, cultural discrimination).

Here are some examples:

• “Client reports continued difficulty managing parenting responsibilities while navigating work demands.”
• “Chronic fatigue and pain continue to limit social participation and daily routines.”
• “Client has resumed part-time work and reports feeling more capable managing interpersonal interactions.”

Including these sections helps communicate the clinical necessity of ongoing treatment—especially in systems where third-party payers require justification. For instance:

• “Client presents with moderate impairment in daily functioning, including difficulties maintaining work attendance and managing emotional regulation in interpersonal contexts.”

4) Assessments

Here we ask ourselves:

💡 Did I use any clinical tools or measures today, and what did they indicate?

If standardized measures were used during the session (e.g., PHQ-9, GAD-7, PCL-5), note the tool and summarize findings in clinical terms, for example:

• “Client’s responses on the PHQ-9 indicate a continued moderate level of depressive symptoms, consistent with presentation.”
• “GAD-7 score decreased from 16 to 10, suggesting moderate anxiety remains but shows improvement.”
• “Administered PTSD Checklist (PCL-5); score suggests continued post-traumatic stress symptoms.”
• “Client completed mood tracking journal; entries showed increased mood variability over the past week.”
• “Suicide risk screening conducted; no current intent or plan reported.”

We might also ask ourselves:

💡 What is my clinical assessment of the client today?

Here are some examples of how we might convey this:

• “Current symptoms suggest ongoing trauma-related activation, especially in response to perceived threat or criticism.”
• “Client appears to be functioning in a mildly dissociative state; affect is flattened, and emotional contact is limited.”
• “Presentation suggests a return to maladaptive coping strategies, likely related to increased stress and perceived lack of control.”
• “Client is demonstrating growing psychological insight, though continues to avoid direct exploration of core fears.”
• “Mood appears reactive and may be related to underlying schema of unworthiness and fear of rejection.”

The Assessment section can be considered optional but may be especially helpful for documenting treatment progress over time or for required outcome tracking.

5) Themes

Here we document what was explored during the session—briefly and in general terms.

We might ask ourselves:

💡 What were the main issues or topics the client explored in this session?

Rather than recounting exact events, describe categories or therapeutic themes. Here are some examples:

• “Client discussed ongoing difficulty asserting boundaries with mother.”
• “Explored ambivalence about ending a romantic relationship.”
• “Client reflected on long-standing fear of abandonment and its impact on friendships.”
• “Focused on managing perfectionism in academic and professional life.”
• “Discussed meaning and guilt associated with a recent loss.”
• “Session centered on body image distress and critical self-talk.”
• “Began exploring narratives from childhood that inform current relationship dynamics.”
• “Client explored ongoing feelings of guilt related to caregiving responsibilities.”
  “Session focused on recent panic episodes triggered by social situations.”

Avoid including sensitive or extraneous personal details. This protects client privacy if records are ever subpoenaed, audited, or reviewed by insurers. Of course, when risk disclosures occur (e.g., suicidal ideation or suspected abuse), the note must reflect what was said and what actions were taken, including quotes and a record of all clinical steps. In such cases, you may also consider writing a separate Risk Assessment report (I have a blog post dedicated to doing just that).

6) Treatment

This is where we record our own role in the session:

We ask:

💡 What clinical interventions did I use, and how did the client respond?

Therapeutic Interventions:

Document how you responded to the client’s presentation. Some examples include:

• “Validated the client’s emotional experience and used active listening to support emotional regulation.”
• “Introduced the window of tolerance model to normalize emotional dysregulation during trauma processing.”
• “Challenged catastrophic thoughts through guided Socratic questioning.”
• “Provided psychoeducation on attachment patterns and their origins.”
• “Facilitated a grounding exercise during moments of emotional flooding.”
• “Explored inner child imagery to access vulnerable emotions.”
• “Offered CBT reframing of automatic thoughts”
• “Supported reflective processing of grief”
• “Reviewed prior safety plan and reinforced crisis resources”
• “Provided psychoeducation on anxiety and avoidance cycles”

This is an extremely important part of our therapy documentation (and sometimes overlooked by clinicians) – we must be able to show that we did intervene and that we did so appropriately. Even if the work felt subtle—say, sustained empathic listening—it is still worth noting.

Client Response to Treatment:

It is also important to describe how the client reacted to your interventions and the session more generally. Here you may describe:

• Insight gained
• Emotional response to the session
• Resistance or concerns about the process
• Therapeutic alliance dynamics

Some examples include:

• “Client appeared engaged and expressed relief at learning how trauma impacts the nervous system.”
• “Initially resistant to reframing techniques but later expressed curiosity and openness.”
• “Became visibly tearful during discussion of grief; stated they felt a ‘release.’”
• “Client expressed frustration with therapy, stating, ‘I know you’re trying to help, but it’s too hard right now.’”
• “Demonstrated increased self-reflection and willingness to challenge long-held beliefs.”

This helps capture the flow of the treatment relationship over time.

7) Progress

This final section summarizes movement, change, or ongoing areas of concern.

We might ask ourselves:

💡 What progress or challenges emerged since the last session, and how does this shape the treatment going forward?

Here we can chart such things as any significant developments, ongoing clinical issues, and our updated plan. Let’s look at some examples:

Significant Developments

• “Client reported increased use of coping strategies when experiencing panic symptoms.”
• “Initiated conversation with a sibling after six months of estrangement.”
• “Client successfully navigated a triggering social event with minimal distress.”
• “Client reported decreased frequency of panic attacks and initiated a conversation with a family member previously avoided.”

Ongoing Issues

• “Continues to struggle with guilt when prioritizing own needs.”
• “Client reports ongoing nightmares and intrusive memories.”
• “Still avoiding key emotional topics in session, despite acknowledging their importance.”
• “Continued difficulty tolerating shame-based emotions during interpersonal conflict.”

Updated Plan

Here we can include such things as:

• If the treatment focus has shifted, note how
• If the original treatment plan remains, confirm it
• Document homework assigned or topics to revisit
• Note next session date and frequency

Documenting Medical Necessity

This section is also a good place to reinforce why treatment is clinically needed. For example:

• “Client continues to meet criteria for treatment due to persistent anxiety and functional impairment. Treatment remains medically necessary to reduce symptom severity and support occupational and relational functioning.”

This type of phrasing can be especially helpful if progress notes are reviewed for insurance reimbursement or clinical audits.

Here are some more examples of how we may document the updated plan:

• “Client continues to present with clinically significant symptoms of anxiety and emotional dysregulation. Treatment remains indicated to address underlying trauma and improve relational functioning.”
• “Homework assigned: identify and journal triggers for emotional shutdown.”
• “Next session scheduled for June 28th; weekly therapy to continue at current frequency.”
• “Focus moving forward will include assertiveness training and narrative reconstruction.”

8) Additional Comments

Last, we might consider:

💡 Is there anything else I need to document about the session or the therapeutic process?

Some clinicians choose to briefly document extra-session details here:

• Late arrivals or missed payments
• Requests for documentation
• Upcoming breaks or life events that may affect care

Here are a few examples:

• “Client rescheduled next session due to travel; offered email contact if needed.”
• “Therapist will be away for 2 weeks in July; discussed possible support options during that time.”
• “Client requested letter for academic accommodations; therapist to prepare and send by Friday.”
• “Late arrival by 10 minutes; session extended slightly to allow for debrief.”

Always end your note with your full name, professional designation, date, and signature—digital or handwritten, per your record-keeping standards.

Final Reflections

Progress notes are an essential component of clinical record-keeping. They provide a structured account of each session and support accurate recall, professional accountability, and treatment planning over time.

The level of detail, tone, and content may vary depending on your clinical setting, licensing requirements, or documentation policies. When in doubt, refer to your regulatory body’s guidelines and any applicable organizational policies. If you’re billing to insurance or working with third-party payers, ensure that notes clearly demonstrate medical necessity and document treatment progression.

A clear, objective, and clinically focused progress note helps maintain the quality and integrity of care—and protects both client and clinician when records are reviewed or requested.

At Note Designer, we offer a thoughtfully structured Basic Note template designed specifically for mental health providers. It includes clearly defined sections, built-in drop-downs, and a rich library of professionally written content to help you document efficiently and thoroughly—including clear, editable statements that support medical necessity. Whether your approach is CBT, psychodynamic, trauma-focused, or integrative, Note Designer has you covered (we support over 20 different treatment approaches), and you can tailor the template to fit your clinical style and workflow with ease. In addition to our standard Basic Note for individual therapy, our platform also offers flexible options to support a range of documentation styles. Note Designer also includes an optional AI-Rewrite feature that can help polish your note once it’s drafted. Whether you want to refine the phrasing, improve flow, or ensure a more professional tone, the AI-Rewrite offers gentle editing support—always keeping your clinical voice intact. It’s there when you need it, and completely optional.

By Patricia C. Baldwin, Ph.D.

Clinical Psychologist

Co-Founder Note Designer Inc.

Author of

Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2^nd Edition – updated and expanded); 2023.

👩🏻‍💻 This blog post is derived from Chapter 3 of Note Designer: A simple step-by-step guide to writing your psychotherapy progress notes (2^nd Edition- updated and expanded); 2023

© 2025 Patricia C. Baldwin. All rights reserved.
This blog post is the intellectual property of Patricia C. Baldwin and may not be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the author. Brief quotations may be used with appropriate citation and link to the original source.