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Client Progress Notes Template

Transform Your Patient Tracking with an Accessible Progress Notes Template

Tracking changes in a patient's health can be chaotic without the right tools. This client progress notes template is designed for healthcare professionals who need a structured way to record patient observations effectively. With this template, you can ensure accurate documentation, improve communication with your team, and enhance patient care by systematically tracking both positive and negative changes. Plus, it meets WCAG standards, ensuring accessibility for all users. Explore the live template to start organizing your notes effortlessly.

Use this Template (FREE) Live Preview
Client full name
Client ID or record number
Date of session
Session type
Please Specify:
Session format
In person
Video (telehealth)
Phone (telehealth)
Text-based chat
Prefer not to say
Other
Please Specify:
Session duration
15 minutes
30 minutes
45 minutes
60 minutes
75 minutes
90 minutes
Over 90 minutes
Not recorded
Attendance status
Attended
Late arrival
No-show
Cancelled by client
Cancelled by provider
Rescheduled
Session focus or key topics
People present
Client
Parent or guardian
Partner
Family member
Case worker
Other provider
Interpreter
Other
Please Specify:
Mental status observations (select all that apply)
Overall change in symptoms since last session
Much worse
Slightly worse
No change
Slightly improved
Much improved
Not applicable
Additional clinical observations (optional)
Primary symptoms frequency since last session
Never
Rarely
Sometimes
Often
Always
Suicidal ideation reported or observed
Yes
No
Self-harm behavior or urges
Yes
No
Homicidal ideation or threats toward others
Yes
No
Risk details, rationale, and safety planning notes
Risk management actions taken (if any)
None required
Reviewed existing safety plan
Created or updated safety plan
Referred for urgent evaluation
Contacted emergency services
Contacted support person
Restricted access to means
Not applicable
Other
Please Specify:
Interventions used this session (select all that apply)
Please Specify:
Client engagement during session
Poor
Fair
Good
Very good
Excellent
Client affect at end of session
Very unhappy
Unhappy
Neutral
Happy
Very happy
Homework or practice completion since last session
Completed all tasks
Completed some tasks
Did not complete tasks
No tasks assigned
Not applicable
Client consented to the plan discussed
Yes
No
Primary goal addressed today
Progress toward the primary goal
No progress
Minimal progress
Some progress
Significant progress
Goal achieved
Not applicable
Evidence or examples supporting the progress rating
Tasks or homework assigned (details)
Next appointment date
Planned actions before next session (select all that apply)
Continue current interventions
Introduce new intervention
Assign homework or practice
Coordinate with other provider
Provide resources or referrals
Update safety plan
Schedule check-in before next session
No changes planned
Other
Please Specify:
Diagnosis code(s) (e.g., ICD-10)
Clinician signature (type full name)
Signature date
I attest that these progress notes are accurate and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
{"name":"Client full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Client full name, Client ID or record number, Date of session","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
paper art illustration depicting a client progress notes template for article about FormCreatorAI

When to use this form

Use this form when you need a clear, repeatable record of a client session or visit. It helps therapists, counselors, case managers, and SLPs track goals, interventions, risk, and next steps. Examples: document a weekly CBT session, summarize a home visit, or note a medication change after a telehealth check-in. If you work in schools, align your entries with the School counseling progress note form to capture student supports and outcomes. In medical or rehab settings, pair it with the Patient progress notes form to record symptoms, vitals, and the plan of care. Consistent notes show progress over time, support billing and supervision, and make handoffs safer.

Must Ask Client Progress Notes Questions

  1. What is the session date, time, and service type?

    Time-stamping and naming the service (e.g., individual therapy, med check) support billing, authorizations, and audits. It also lets you match entries to the correct episode of care and run clean reports.

  2. What goals or treatment objectives did you focus on today?

    Calling out the exact objectives ties the session to the plan of care and shows measurable progress. It keeps your work targeted and makes supervision and peer review straightforward.

  3. Which interventions did you use, and how did the client respond?

    Listing techniques and client response captures clinical reasoning and outcomes. This detail guides your next session and justifies any change in approach.

  4. What changes in symptoms, risks, or functioning did you observe?

    Tracking shifts in mood, behavior, safety, and daily functioning flags escalation early and supports risk management. In psychiatric settings, align entries with the Outpatient psychiatric progress note form to capture risk and medication updates.

  5. What is the plan for next steps, homework, or referrals?

    Clear next actions improve adherence and continuity across providers. They also create a defensible trail for billing and outcomes reporting.

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