Clinical template
Therapy Notes Template with Examples
A therapy progress note records one psychotherapy session: what the client brought, what you did, how they responded, and what happens before next time. It is not a mental status exam. Put MSE findings on that page of the chart if you need them; do not let a laundry list of appearance and thought-form eat the intervention.
Blank therapy progress note
Copy this for CBT, IPT, emotion-focused, or integrative work. Name the method you actually used. 'Supportive listening' is allowed when that is what happened; it is not a disguise for a session with no plan.
Therapy progress note
Date / start–end time / duration / modality (in-person, video, phone): Clinician / designation / location: Client: [initials, age] | Session # | Others present: Consent / recording / third-party presence confirmed: Treatment goals (from the shared plan): Risk this session (SI/HI/self-harm/means/intent) / protective factors: Session focus (what the client brought): Interventions (name the method: exposure, cognitive restructuring, IPT role dispute, chair work, behavioural activation, etc.): Client response (affect, engagement, new material, resistance): Homework / practice before next session: Progress toward goals (one or two sentences, not a score unless you used a measure): Plan: next session date, any coordination (GP, psychiatrist), crisis plan if risk changed: Signature / designation:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, or for your modality's ethics code. Review every generated note before it enters the chart.
Progress notes are not an MSE
A mental status exam describes appearance, behaviour, speech, mood, affect, thought, perception, cognition, insight, and judgment at a point in time. That belongs in intake, in crisis, and when the picture changes. A weekly CBT note that opens with 'groomed, linear, no SI' and never names the exposure is the wrong genre.
| Put in the therapy note | Put elsewhere or skip |
|---|---|
| Goal, intervention, response, homework, risk this hour | A full MSE copied from last week |
| Enough content that a covering clinician could continue care | Verbatim process notes of every association (keep those, if you keep them at all, out of the official record per your college) |
| Measures you actually administered (PHQ-9, GAD-7, session rating) | Scores you guessed |
| Coordination with the GP or psychiatrist | Gossip from a partner who is not in treatment |
In Canada the clinical record is generally producible in a complaint, a college investigation, or a court order. US 'psychotherapy notes' under HIPAA are a different legal object. Write as if the client may read this. Do not write as if nobody will.
Example 1 — CBT, generalized anxiety
Individual CBT, session 6 of 12
34-year-old woman, Toronto. Video, 50 minutes. Fictional.
Session 6/12. Video. GAD-7 today 11 (was 16 at session 1). Goals: reduce worry time, return to driving on highways. Risk: no SI/HI. Sleep improved to 6.5 h. Focus She avoided the 401 on-ramp twice this week (homework was one ramp with the written worry record). Shame about "failing" the task. Interventions 1. Normalized avoidance as the target, not a moral failure. 2. Reviewed the worry record: probability of crash written as 80%, evidence 0 events in 12 years of driving. 3. Designed a graded exposure: passenger on the ramp Sunday, driver on a quiet ramp Tuesday, not the 401 yet. 4. Scheduled a 15-minute worry window at 19:00, postpone-and-park the rest. Response Affect shifted from shame to irritation at the worry, which she could use. Engaged. No dissociation. Agreed to the quieter ramp. Homework Worry window daily. One quiet-ramp drive. Continue sertraline as prescribed by GP (I do not manage meds). Plan Session 7 in one week. If she cannot complete the ramp, we drop a step, not the plan. GP remains MRP for medication.
Example 2 — IPT for depression
Interpersonal psychotherapy, session 4
52-year-old man, Québec City (English-speaking clinic). In-person, 50 minutes. Fictional.
Session 4/16. IPT, role-dispute focus. PHQ-9 today 14. Risk: fleeting SI without plan, as previously; safety plan unchanged, sister is contact. No increase today. Focus Argument with adult daughter about whether he "showed up" after the separation. He came in wanting me to agree he was a good father. Interventions Linked the dispute to the IPT inventory (communication, expectations, role after marital separation). Role-played one 10-minute conversation using "I" statements and one specific ask (Sunday dinner, not a verdict on the past 20 years). Did not adjudicate who was right. Response Tearful, then organized. Able to name the wish (contact) under the anger. Homework accepted. Homework One phone call with the script. No alcohol the evening of the call (his rule). Journal the daughter's actual words, not the interpretation. Plan Session 5 next Thursday. If SI intensifies after the call, he pages the clinic crisis number reviewed today. Psychiatrist continues bupropion; I sent a two-line update with his consent.
Example 3 — trauma-focused follow-up
Trauma processing, session 9
27-year-old non-binary client, Winnipeg. In-person, 60 minutes. Fictional.
Session 9. Prolonged-exposure adjacent protocol as agreed. They/them. PCL-5 not repeated today. Risk: no SI/HI. Grounding intact at end of session. Sleep still broken 2 nights/week. Focus Continued imaginal exposure to the index assault (already in the treatment plan; not re-described in detail in this note). In-session SUDS 70 → 45. Interventions Imaginal exposure 25 minutes, processing 15 minutes. Titrated, not flooded. Grounding (5-4-3-2-1) at end. Did not open a new trauma memory today. Response Able to stay in the memory with eyes open. Some nausea, resolved with feet on floor. They asked to stop once; we paused, then resumed by agreement. Collaborative. Homework Listen to the session recording once, not at bedtime. Continue walking to the grocery store (in-vivo list item 4). Partner not present for homework. Plan Session 10 in one week. If nightmares spike >3 nights, message me and we slow the recording homework. MRP family physician aware of therapy; no meds change discussed.
Mistakes in therapy notes
- Writing an MSE and calling it a progress note.
- No named intervention, so nobody can see what treatment was delivered.
- Verbatim trauma narrative in a record that will be requested by an insurer.
- Risk left blank on a session where mood dropped.
- Homework that is 'think about it,' with no behaviour.
- Comments about a partner, employer, or child who is not the client, beyond what is needed for the work.
CRPO, provincial colleges of psychologists, and social-work regulators all expect a timely record of the professional service. A generated draft that invents an exposure you did not do is a college problem the moment you sign. Read the intervention line.
Draft the session note, keep the method honest
Scribeberry can draft a therapy progress note from the session or from your dictation, using your headings. Edit risk and interventions, then Smart Push into Jane, Accuro, OSCAR, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What belongs in a therapy progress note?
Session time, goals, risk this hour, the focus the client brought, the interventions you used, the client's response, homework, and the plan for next time. That is enough for continuity. It is not a transcript and it is not an MSE.
How is a therapy note different from a DAP or SOAP note?
DAP (Data, Assessment, Plan) and SOAP can hold a therapy session if you put the intervention in Data or Plan. A dedicated therapy template makes the method and homework harder to skip. Use the format your clinic requires; keep the same ingredients.
Are therapy notes confidential in Canada?
They are part of the clinical record and are protected by provincial health-privacy law, but they can be produced in a college complaint, a court order, or with client consent. Write accordingly. Do not assume a US-style psychotherapy-notes privilege.
Can Scribeberry write therapy notes?
Yes. Pick a therapy template, record (with consent) or dictate after the session, and generate. You review risk, interventions, and anything that should stay out of a third-party file before signing.
Templates
