PDF
Word
Psychotherapy Progress Note Template
Psychotherapy Progress Note Template: What Is It?
A Psychotherapy Progress Note refers to a detailed medical form that records the development of mental health treatment, allows the patient to set new therapy objectives, and lets the doctor track the patient's accomplishments. A therapist and their patient are supposed to work together in order to seek positive changes in the patient's life helping the latter to become more happy, healthy, and productive. A document that focuses on the achievements of the patient on the way towards this goal will indicate the effects of the selected treatment and show both people involved techniques that worked and that failed so that the approaches can be adjusted if necessary.
You can find a Psychotherapy Progress Note template through the link below.
How to Write Psychotherapy Progress Notes?
Use the following Psychotherapy Progress Note checklist during the appointment with the patient:
-
Personal details of the individual - their full name and date of birth . The top of the page may also include other specifics like the date and time of the session and the name of the therapist present. This information is required if you are planning to observe the patient for many months or years since the issue they want to deal with is deep and traumatizing - Psychotherapy Progress Notes can be kept in the patient's file and compared later.
-
Patient's condition on the day of the visit . See if their mood is somehow different from the previous sessions, note any symptoms that manifest as you are talking to them, and determine whether they pose a risk for themselves and others. In case you prescribed any medications in the past or you know they have been taking medicine to alleviate symptoms of depression or anxiety, find out if they continue to take these pills and if they feel any alterations in their physical and mental state.
-
Results of treatment . It is difficult to expect significant results after one or two therapy sessions or be absolutely sure the therapy timeline you have mapped out will be followed without any modifications - still, every month or so you need to assess the patient's response to the techniques you have recommended. Whether you asked them to avoid harmful habits, reach out to their loved ones more, join group therapy, book an appointment with a counselor, or learn to meditate, talk to them and figure out if any of these methods worked for their benefit. Observe the patient's behavior and appearance while you are listening to their words and note any positive or negative changes.
-
Conclusions of the therapist and new interventions proposed to the patient . There is nothing wrong with adopting new strategies while assisting the patient who tries to navigate their life and get used to major changes. If you found the solutions you have offered before did not work, analyze the reasons and opt for new techniques the patient can practice on their own, in a group setting, or with you and other mental health professionals.
Still looking for a particular template? Take a look at the related templates below:
