How To Take Progress and Process Therapy Notes? (Examples, Free Templates)

Whether you’re a practicing therapist, a psychology student nearing graduation, or a clinic manager, understanding how to take therapy notes is a skill you’ll need sooner or later.

Instead of writing, Talked about a bunch of stuff. She was kind of sad but also laughed.

The right way is to write, Sarah reported feeling “drained and emotionally numb” over the past week.

Do you want to know more ways and structured templates you can use to maintain standard therapy notes for your patients? We have explained what progress and process therapy notes are, their examples, and templates.

What Are Progress and Process Therapy Notes?

Progress and process notes are essential tools therapists use to document sessions, evaluate client growth, and support clinical decisions. While they may sound similar, each serves a distinct role in treatment planning and professional accountability. Your therapist and you may set some goals for your sessions which can also be tracked using these note-taking systems.

What are progress therapy notes?

Progress Notes are treated as formal, clinical records that report each detail of the client’s session with the therapist. It includes all things like treatment goals, interventions, responses, and progress. 

For example, if a client switches therapists, progress notes allow the new provider to quickly understand treatment history, goals, and risks, ensuring continuity of care.

Only the client, other health providers, and insurance companies are allowed to access these therapy notes.

While taking progress notes, you will include:

• Date, time, and type of session
• The client’s symptoms and diagnosis
• Interventions used
• Client’s response and progress
• Plans for future treatment
• Any risk or safety concerns

What are process therapy notes?

Process Notes or Psychotherapy Notes are informal and private records that a therapist uses to track their interpretation of the client’s case. These include any reflections, observations, and hypotheses for each session and treatment the client goes through.

These notes often capture subtle emotional shifts, therapist countertransference, or emerging patterns that aren’t immediately relevant to a diagnosis. They can also be used during supervision or peer consultation to improve therapeutic outcomes. 

These notes can be seen as important in clinical decision-making and personal development of a therapist. These are not part of medical records and are protected by privacy laws, like HIPAA (Health Insurance Portability and Accountability Act).

Also, the sharing of this document requires written consent from the client. Even direct guardians (mother, father, sister, brother) may not be able to access this information. However, if there is a court order, warrant, subpoena, or even a dangerous situation for the individual or public, these records can be released without needing the consent of the client.

Note: These are good to use as a reference in clinical supervision on each case to show that you are being supported in your clinical work, the more hands on deck the better.

The Differences Between Progress and Process Therapy Notes

While both progress and process notes are meaningful parts of a therapist’s documentation, they serve different purposes. They also have varying formats and legal considerations. We have researched and mentioned some differentiating factors:

• Purpose: Progress notes are a part of medical records and follow a very formal language structure. While process notes are more personal and have a very informal approach in terms of wording and form.
• Content Focus: Contents, such as session summaries, symptoms, and diagnoses are a part of progress notes. As a therapist if you are keeping some personal notes of the observations, personal impressions, and such they come under process therapy notes.
• Access and Legal Protections: In legal settings, only progress notes may be subpoenaed without patient consent. Process notes remain protected unless a clear threat to safety is established, making them safer for therapists to explore sensitive material.
• Storage Requirements: In digital practice, therapists often use EHR (Electronic Health Record) systems to manage progress notes, while process notes may be stored separately, handwritten, or in encrypted files.
• Documentation Style: Progress notes are quite structured using formats, such as SOAP, DAP, BIRP, and others. Again, process notes do not need such formats, though they should be clear and avoid mentioning certain medical data.

Why Are Therapy Notes Important for Clinical Practice?

Whether you are jotting down progress or processing therapy notes, they are important records that can’t be ignored. Therapy notes have become a factor of ethical and effective clinical practice. The continuity of care, document clinical reasoning, and support of client outcomes develops overtime.

These notes are a great way for a therapist to track goals, assess treatment effectiveness, and reflect on their own therapeutic approach. Most importantly, there was a study that explored how therapy notes have an impact on the client’s progress. About 60% to 78% of patients reported that reading their doctor’s notes helped them take their medications as prescribed.

Both progress and process therapy notes help therapists make better clinical decisions. By reviewing these notes, practitioners can spot patterns, adjust their strategies, and plan future sessions with greater clarity and purpose.

Questions like such:

Q. How do therapy notes improve treatment outcomes?

Q. What role do therapy notes play in clinical decision-making?

Q. How do notes help therapists track client progress over time?

Q. How do therapy notes support evidence-based practice?

Q. Can therapy notes reduce the risk of legal and ethical issues?

This can be answered by knowing how therapy notes help clients know more about their treatment journey. It helps them fully accept who they are and what they want.

Therapy Note Templates Used by Professionals

Even though you might be taking down notes, you might not be following any particular formats. But, now the question stands, what is the best therapy note template anyway?

According to the Centers for Medicare & Medicaid Services (CMS) and the California Department of Health Care Services (DHCS) provide detailed guidelines on how to take therapy notes that can also be cited as medical records in the future.

However, certain templates, like SOAP, DAP, or BIRP are government-recognized and accepted which is much easier for a therapist to follow.

SOAP Template

The SOAP template is used to create standardized clinical and insurance documents that are accepted by other medical professionals and other people involved. The abbreviation’s full form is the approach you have to use to create therapy notes for your patients.

• S – Subjective: Client’s reported feelings, symptoms, or concerns in their own words. For example, “I’ve been feeling more anxious at work and can’t sleep well.”
• O – Objective: Clinician’s observations and measurable findings (mood, behavior, affect). For instance, the client appeared restless, avoided eye contact, and fidgeted throughout the session.
• A – Assessment: Therapist’s clinical judgment based on subjective + objective data. Suppose, your client’s anxiety symptoms have increased, possibly due to upcoming project deadlines.
• P – Plan: Next steps for treatment, referrals, interventions, or follow-up. Such as, your client begins CBT for anxiety management; and is assigned thought record homework.

DAP Template

Meaning data, assessment, and plan, the DAP template helps therapists pen down observations and clinical data equally. This helps the records have some contextual meaning which can help other medical professionals make better clinical decisions.

• D – Data: This is equal to factual information, what the client said, and how they behaved. Take for instance if your client reported irritability at home; and appeared tired and disengaged.
• A – Assessment: Is the therapist’s interpretation or clinical impression. Like sometimes clients may be experiencing burnout; so their symptoms align with depressive patterns.
• P – Plan: These be indicated as strategies for the next session or ongoing goals. A good example is discussing boundaries at home; and introducing coping techniques for mood regulation.

BIRP Template

This template is unique and mostly focuses on behavioral health settings. It encourages documentation that is based on interventions based on the active mental illness faced by the patient or client. 

• B – Behavior: Recording the client’s behavior or reported experiences in the session. Examples like client describing their daily panic attacks and isolation.
• I – Intervention: Techniques used by the therapist during the session. You may see it utilized in ways like guided breathing; and initiated cognitive restructuring exercises.
• R – Response: Client’s reaction to interventions. Namely, the client engaged well and reported feeling “a bit calmer” after the breathing exercise.
• P – Plan: Next session focus on homework. Think of practicing breathing daily; explore panic triggers in the next session.

GIRP Template

This is a very specific template that is used for group therapies and sessions that have communities. As a therapist, you will have to write notes in a very specific manner as there is more than 1 person in a group.

• G – Goal: The primary objective or treatment goal for the session. Let’s say, an increase in social interaction and reduce feelings of isolation.
• I – Intervention: What the therapist did or facilitated to address the goal. Illustrated by a group role-play on assertive communication.
• R – Response: How the client(s) responded to the intervention. Sometimes clients actively participated and expressed feelings heard by peers.
• P – Plan: Next steps in therapy. You can encourage continued participation; plan for the assertiveness worksheet.

PIE Template

The PIE template is used to address sessions that require quick documentation or less paperwork. Some instances can be crisis intervention and case management. Though done rarely, some therapists (working with sensitive clients) might need this approach.

• P – Problem: What issue is being addressed? In some cases, clients reported suicidal ideation without intent or plan.
• I – Intervention: What did you do to help? For example, conducted suicide risk assessment and safety planning.
• E – Evaluation: Was it effective, or is further action needed? To give an example, the client agreed to daily check-ins and removed access to means.

SBAR Template

SBAR therapy note template helps with interdisciplinary teams, handoffs, or high-acuity clinical settings. This is also used in a looked-after medical use setting (involving some form of medication, like psychedelics) where note-taking might determine future therapeutic choices.

• S – Situation: What’s happening now? Seek out if your client is presented with panic symptoms during intake.
• B – Background: Relevant history or context. Like, a previous diagnosis of GAD; recently lost job.
• A – Assessment: Therapist’s current impression. See if the notes mention things like acute anxiety, no risk of harm. Client is open to treatment.
• R – Recommendation: Next action or referral. Follow-up examples, schedule psychiatry consult; and start psychoeducation on anxiety.

HEAP Template

This is a customized format used by trauma-focused therapist. It is treated more as a holistic and trauma-focused approach that helps in specific note-taking. These note-taking guidelines can help you manage your practice-related conversations better.

• H – History or Highlights: Key client updates or life events since the last session. For instance, the client disclosed flashbacks triggered by a recent movie.
• E – Emotions: Client’s emotional state or affect observed or reported. For instance, tearful but composed; and reported feeling “numb.”
• A – Action or Approach: What was done in session to address the concern. Including, used grounding technique and re-established safety plan.
• P – Plan: Follow-up goals or assignments. You can try to continue grounding work; introduce EMDR in 2 sessions.

How To Write Progress Notes: A Step-by-Step Guide

Writing progress notes is different from writing process notes. If you’re a therapist who isn’t using a specific format for note-taking yet, this guide will help you learn how to write effective progress notes for your practice.

Step 1: Begin with Identifiers and Administrative Info

Start each note with clear client and session identifiers. This ensures organization, continuity, and compliance with documentation standards. Make sure to include:

• Client’s full name and ID (if applicable)
• Date of session
• Session number and type (e.g., individual, group, family)
• Duration of the session (e.g., 50 minutes)
• Therapist’s name and credentials
• Modality (in-person, telehealth, home visit)

Now you might be thinking, if your client is billing insurance, then is it the same list of documents, and to that, we say absolutely not. Below is an insurance billing checklist for a clinical note:

• ICD-10 Diagnosis Code(s)
• CPT Code (Procedure Code)
• Date of Service
• Start and End Time (if required by the payer)
• Provider Information
• Place of Service Code
• Client Information

Also, most therapists miss out on the fact that their clinical notes should meet some goals and state some factors clearly. Even after mentioning the above in your clinical notes, double-check to see if the following details are also mentioned:

• Diagnosis
• Why the client needs ongoing treatment
• Progress or changes in symptoms
• Interventions used
• Plan for next steps – Treatment Goals

If you have no idea about how to write therapy notes starting with basic details, you can cite the below example.

Step 2: Choose a Standardized Format

Choose a format based on organizational policy or insurer requirements. The most common and widely accepted formats include the ones we have mentioned above. You can use SOAP: Subjective, Objective, Assessment, Plan; DAP: Data, Assessment, Plan; or BIRP: Behavior, Intervention, Response, Plan. If your client needs insurance reimbursement and legal mandate of their medical records, SOAP is the best format to use.

Step 3: Document the Subjective Section

The subjective section refers to the client’s words, emotions, thoughts, and self-reports they may be making during the session. Things are stated as they are or “verbatim” as no interpretive data has any use when it comes to subjective therapy notes.

While the information in this section can vary from case to case, some details should always be included. These can be the client’s main concerns, quotes that show strong emotions or core beliefs, signs of progress or setbacks, and input from caregivers or family members (when relevant).

Some therapists mention these subjective thoughts in the dedicated section as such:

“I feel like my anxiety is controlling every part of my life. Even grocery shopping is too much.”

The client reported difficulty sleeping, frequent worry, and low motivation since the last session.

Step 4: Document the Objective Section

Now comes the objective section in which as a therapist you start documenting your observations. Usually, this section should be as professional as possible because this is the section that is referred for insurance and further medical decision-making. 

You should mention the appearance, affect, speech patterns, and behavior of your client, mental status exam observations (orientation, thought process, insight), measurable changes from previous sessions, and standardized tool scores.

• PHQ-9 – Assesses the severity of depression.
• PCL-5 – Screens for PTSD symptoms.
• Y-BOCS – Rates severity of OCD symptoms.
• DAST-10 – Detects drug abuse issues.
• CORE-10 / CORE-OM – General psychological distress.
• HAM-D – Clinician-rated depression scale.
• HAM-A – Clinician-rated anxiety scale.

These scores will be helpful in evaluating how far along your client is, if their treatment plan is working, or if your client should continue with their therapy. 

Step 5: Provide a Clinical Assessment

This is a very important step for a therapist to include while they are penning their therapy notes. You should provide a clear, short, and specific assessment clinically. Think of it as your professional judgment after you have analyzed all subjective and objective data. 

A good example will be “Client shows some improvement in anxiety; still exhibits catastrophic thoughts and avoidance”. This shows multiple details about the progress of treatment and the clinical diagnosis that has been made till now.

Step 6: Outline the Treatment Plan

Therapists should always outline the future treatment plans for a client. To better supervise what might be the best approach for a patient, try and write in your notes if your client needs to “continue with the DBT framework” or if “DBT tools need to be introduced in the next session”.

Step 7: Assess Risk and Ethics

It is your responsibility to assess all the risks and ethics. These considerations are very important, as the client can be misguided into risky approaches with little to no benefit at all. Especially, if your client struggles with suicide or extreme self-harm, you will need to know about:

• Suicide/self-harm risk levels
• Homicide risk or harm to others
• Duty to warn/Duty to protect instances
• Mandated reporting triggers
• Informed consent and confidentiality reminders

If you are an experienced therapist, you can note these factors in the following way:

No SI/HI expressed. Safety contract reaffirmed. The client denied abuse but expressed fear about the home environment, exploring further next session.

Step 8: Sign and Secure the Note

Sign the note (you have prepared for your client) with full credentials and date of entry. If using an EHR, ensure you log out properly and encrypt the file per HIPAA guidelines.

For instance, a therapist will sign:

Dr. Alicia Riley, PsyD | NPI: 1234567890 | Date: 05/13/2025

More tips to write better therapy notes:

• Be concise yet detailed to be clinically significant.
• Use clinically relevant terminology and language with DSM-5 and ICD-10 when relevant.
• Stay objective and use observable data, not assumptions.
• Describe behaviors, not traits (e.g., “client displayed aggression,” not “client is aggressive”).
• Check previous notes before continuity.
• Maintain accuracy by taking into account the client’s identity, context, and values.

Disclaimer: All the examples used in this content are fictional. If there is any correlation or resemblance to real individuals, events, or situations, it is purely coincidental.

How To Write Process Notes: What To Include and Avoid

Process notes are much easier to write for a therapist. These notes are quite confidential and are NOT a part of a client’s medical records. The thing that makes these notes so different is that the therapist may keep such notes to deflect on a session, hence containing quite personal information. Due to this, such psychotherapy notes are protected under HIPAA and other similar laws.

If you are looking for steps to write process notes, there are none. No standardized formats or writing styles are particularly added to process notes. Though, as a budding therapist, you should know what to include. Below is a list of things we urge you to include in your process notes.

• Add Subjective Notes and Observations: As these are for personal reflection, include as much detail as possible. You can write “client shifted in tone when father’s topic was brought up” and similar language.
• Emotional Countertransference or Somatic Reactions: Any reactions you may have to the session should be recorded. If you felt “irritated” when the client over-stretched a topic or you felt “anxious” due to a client’s relatable situation, all should be recorded.
• Do Not Structurize: You are not using these process notes to make a clear diagnosis or prognosis. Try to understand thought patterns and write them as necessary.
• Questions and Hypothesis: Document any theories you may have for their situation. Rather than suggesting it to the client, start by jotting down your questions in process notes “Is the client showing early signs of self-harm?”.

You should not include any personal, identifiable, diagnosis, billing codes, coordination of care, or other therapies used for treatment. As this data is stored personally in a private folder or system compliant with HIPAA 45 CFR §164.501, you should be extra careful.

Examples of Therapy Note-Taking for Psychedelic Therapies and Normal Therapeutic Approaches

Every therapist who is starting out or is adjusting to these standardized formats, therapy note examples can help you understand where and how to begin. You might be a little confused even after our step by step guide, so here are some note-writing samples that can help you out.

At the Ko-Op, we use the following template for our psychedelic note-taking responsibilities:

Progress Note Example (DAP Format) (CBT Lens)

Client: Jane Doe
Date: 05/13/2025
CPT: 90837 (60-minute psychotherapy)
ICD-10: F33.1 – Major depressive disorder, recurrent, moderate
Location: TelehealthProvider: [Therapist Name], LCSW | NPI: [#]

D (Data):

The client presented with ongoing symptoms of depression, including low mood, fatigue, feelings of worthlessness, and difficulty concentrating. She linked her depressive symptoms to childhood experiences of physical abuse by her father. In the session, we utilized CBT to identify and challenge core negative beliefs, such as “I’m not good enough.” Therapist introduced thought-tracking and guided client in developing more balanced self-statements. The client practiced restructuring one automatic thought in session.

A (Assessment):

The client is demonstrating increased insight into how early trauma has shaped her internal narrative and cognitive distortions. She engaged meaningfully in cognitive restructuring and was receptive to thought-challenging techniques. The mood remains low, but she is motivated and able to reflect on her patterns. No current risk of harm or safety concerns were reported.

P (Plan):

1. Assign thought log homework to identify automatic negative thoughts.
2. Continue cognitive restructuring and begin exploring core beliefs.
3. Reinforce the use of coping statements.
4. Monitor symptoms of depression and suicidality.

Next Session: 05/20/2025

Progress Note Example (DAP Format) (IFS Lens)

Client: Jane Doe
Date: 05/13/2025
CPT: 90837 (60-minute psychotherapy)
ICD-10: F33.1 – Major depressive disorder, recurrent, moderate
Location: Telehealth
Provider: [Therapist Name], LCSW | NPI: [#]

D (Data):

The client presented with continued symptoms of depression—sadness, hopelessness, and self-critical thoughts. She linked these symptoms to a history of childhood physical abuse by her father. Using an Internal Family Systems (IFS) approach, we identified and dialogued with an insecure adolescent part holding fear and shame. The therapist supported unblending and helped the client access Self-energy to begin building a compassionate relationship with this part.

A (Assessment):

The client is deepening her capacity to recognize and relate to internal parts shaped by trauma. The insecure part that dominates during vulnerable moments was identified and met with empathy. The client showed emotional engagement and insight into how this part contributes to current depressive symptoms. No risk of harm or safety concerns were disclosed.

P (Plan):

1. Continue building trust and communication with the insecure adolescent part.
2. Encourage journaling to support unblending and Self-led inquiry.
3. Deepen exploration of protective strategies tied to trauma.
4. Monitor mood, dissociation, and emotional reactivity.

Next Session: 05/20/2025

Process Note Example (Psychotherapy Notes)

The client appeared emotionally withdrawn today. Noted several long pauses before responding. When asked about work, eyes darted downward and the voice softened, likely shame-linked affect. Mentioned “feeling like a failure,” a recurring schema from previous sessions. Suspect internalized parental criticism may be influencing current stress response. Consider exploring core beliefs around self-worth. 

Therapist also noted transference cues, client seemed to seek approval after sharing. Must monitor this dynamic moving forward. Felt therapeutic alliance strengthened by validating client’s emotional experience. May introduce schema-focused intervention to challenge inner critic narrative next week. This note is for clinician’s reflective use only.

Tools and Platforms for Therapy Documentation

Nowadays, more modern and tech-educated therapists prefer using tools that take therapy notes. These are tools and platforms that are specifically used for documenting progress and process notes. If you feel like writing down therapy notes is a hassle, you can look into these automation tools.

1. SimplePractice

SimplePractice is a popular all-in-one practice management tool for therapists. It offers scheduling, a client portal, paperless intake, documentation, telehealth, and billing.

Best Use: Ideal for solo practitioners or small group practices needing full practice management.
Cost: Starts at $39/month (Basic), $59/month (Essential), $99/month (Plus).

Automotive Power:

• Auto appointment reminders
• Insurance claim filing
• Pre-built and customizable templates
• Secure client communication
• Paperless onboarding

2. TheraNest

This is a behavioral health software designed for mental health professionals. You can start taking therapy notes, schedule, bill, create assessments, and group practices with intuitive features and secure document storage.

Used For: Best for group practices and clinics with multiple providers.

Price: Starts at $39/month for 1–10 clients; pricing scales with client volume.

Automation Features:

• Calendar sync and reminders
• Batch billing & claims
• Progress note templates
• Client invoicing
• Group session support

3. TherapyNotes

TherapyNotes is a highly secure practice management system with a strong focus on documentation, billing, and scheduling for behavioral health professionals. They also provide compliance-friendly templates and EHR features.

Meant For: Best for clinicians needing detailed documentation and insurance billing.

Payment: $49/month for solo users, with team plans available.

Automation Specifics:

• Insurance billing automation
• Integrated to-do list
• Structured progress/process note templates
• Appointment & task reminders
• Credit card processing

4. Google Workspace (for personal psychotherapy notes with HIPAA compliance precautions)

Google Workspace is a cloud-based suite of tools (Docs, Sheets, Drive, Gmail, etc.) that can be configured to meet HIPAA compliance for secure documentation, scheduling, and communication in clinical practice especially documenting psychotherapy.

Designed For: Secure documentation and storage of client notes (with BAA in place)

Charges: Business plans start at $6 to $18/user/month, For HIPAA compliance, you must use the Google Workspace Business Associate Agreement (BAA), which is available with paid plans (Business Standard or higher)

Auto-Drives:

• Limited direct automation for clinical notes
• Can be enhanced using Google add-ons, Docs templates, and integrations with tools like Zapier
• Not built specifically for therapists, but highly customizable for solo practitioners

Choosing the Right Note Style for Your Practice

Whether you are practicing trauma-informed therapies or you are an expert with ketamine-assisted psychotherapy, note-taking is important. At first, you may get confused about if you have to manage both progress and process notes. The answer to that is a definitive YES.

It doesn’t matter if casual notes don’t matter to you, the right note style is to apply both to your practice. If you are a KAP specialist, then it becomes even more important. As you guide your patient under the drug into their exploratory journey, you will need to journal most things down. 

Consider these templates as your helping hand in assisting you to structure and record sessions for future use.

Does Ketamine-Assisted Psychotherapy Is Calling Your Name?

As therapists, you may be open to discovering new and emerging therapeutic approaches. KAP is no different. We at the Ko-Op host a CE-approved KAP training that can help you practice ketamine therapy in legal states of the United States.

If you want to start practicing ketamine-assisted psychotherapy, reach out to us:

If you are a patient or have other patient referrals for us, contact us below:

Choosing yourself starts with choosing the right support. Consider ketamine-assisted therapy.