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Mental Health Progress Notes Form Template

Streamline Documentation for Mental Health Progress

Tracking your clients' mental health progress can be time-consuming and challenging. This Mental Health Progress Notes Form Template is designed for therapists and mental health professionals looking to document sessions efficiently and effectively. With this template, you can easily capture essential client information, monitor treatment goals, and ensure compliance with industry standards, all while improving your workflow and saving time. Plus, it features WCAG-aligned labels for accessibility. Start using the live template to enhance your documentation process!

Use this Template (FREE) Live Preview
Client full name
Client ID or record number
Date of session
Session type
Individual therapy
Couples therapy
Family therapy
Group therapy
Medication management
Assessment/Intake
Crisis session
Case management
Other
Please Specify:
Session duration (minutes)
Session format
In person
Video
Phone
Text/Chat
Hybrid
Primary concerns discussed this session
Please Specify:
Client report of symptoms or changes since last session
Mental status and observable behaviors
Client mood today
Very unhappy
Unhappy
Neutral
Happy
Very happy
Suicidal ideation since last session
Yes
No
Homicidal ideation since last session
Yes
No
Self-harm behavior or urges since last session
Yes
No
Substance use since last session
Yes
No
Risk notes (include context, triggers, and supports)
Overall clinical risk level
None
Low
Moderate
High
Imminent
Interventions used this session
Please Specify:
Client engagement/participation
Poor
Fair
Good
Very good
Excellent
Client response to interventions
Progress toward treatment goals this session
Poor
Below average
Average
Good
Exceptional
Homework or between-session tasks assigned
Diagnoses addressed today (codes optional)
Medication changes or recommendations
Referrals or care coordination planned
Next session date
Billing code(s) for this session
Clinician full name
Clinician credentials
Clinician typed signature (enter full legal name)
Date signed
Release of information on file and valid
Yes
No
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Paper art illustration depicting a mental health progress notes form with creative design elements and vibrant colors.

When to use this form

Use this template right after each therapy session to document symptoms, goals, interventions, and risk. It fits individual, couples, or group work, whether you meet in person or by telehealth. Private practitioners, community clinics, and trainees can keep a consistent progress note format that supports continuity of care and audits. School counselors can adapt it for brief sessions and crisis check-ins; if your work is campus-based, see the School counseling progress note form. For mixed caseloads or multidisciplinary teams, a general option like the Progress note form may be better. Over time, structured notes help you spot trends, adjust treatment plans, and coordinate with supervisors and care teams.

Must Ask Mental Health Progress Notes Questions

  1. What is the client's presenting concern today?

    This anchors the note to the session focus and links back to the treatment plan. Clear phrasing makes it easy to scan progress across visits.

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

    Documenting modality and response shows medical necessity and ties actions to outcomes. It guides what to repeat, modify, or discontinue next time.

  3. What objective observations support your assessment?

    Concrete data (appearance, mood, behavior, measures) strengthens clinical judgment and risk ratings. It keeps your therapy notes defensible and audit ready.

  4. Are there any risks or safety concerns, and what actions did you take?

    Recording risk, protective factors, and steps (safety plan, collateral contact, consult) protects clients and you. If you need guidance or escalation, capture follow-up in the Clinical supervision form.

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

    A clear plan builds continuity and sets expectations the client can follow. For between-session reflections, invite clients to note insights in a Journal entry form.

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