Therapy Progress Note – Brief

Review since last session:

• Describe client’s current presentation, particularly since last appointment
• Severity/Impact: describe impact on current functioning

Past Medical & Psychiatric History:

• Current Medications: List current medications, including dose and frequency
• Recent Substance Use: Details of any recent substance use

Mental Status Examination:

Only include sections stated in the transcript.

• Behaviour: Observe the client’s activity level, interaction with their surroundings, and any unique or notable behaviors
• Speech: If the pace of speech was fast or slow
• Mood: Record the client’s self-described emotional state, using their own words if possible
• Affect: Describe the range and appropriateness of the client’s emotional response during the examination, noting any discrepancies with the stated mood
• Thoughts: Assess the client’s thought process and thought content
• Perceptions: Note any reported hallucinations or sensory misinterpretations, specifying type and impact
• Cognition: Describe the client’s memory, orientation to time/place/person, concentration, and comprehension
• Insight: Describe the client’s understanding of their own condition and symptoms, noting any lack of awareness or denial
• Judgment: Describe the client’s decision-making ability and understanding of the consequences of their actions

Session Content:

• Describe any goals there were discussed, including if any new objectives, desires or things to work on where discussed, or if existing goals were reviewed. When available, describe SMART goals and quote specific aims
• Describe the setbacks and obstacles to progress for therapy goal/objective
• Describe details of other relevant discussions with client during the session, including life circumstances, milestones, relationships, interactions or events important to the client’s well-being, that have either occurred or are upcoming
• List key relationships the client has and key details or interactions

Interventions:

• Describe details of specific therapeutic techniques and interventions used or to be used. If any techniques from Acceptance and Commitment Therapy, CBT, psychodynamic, interpersonal therapy, Schema Therapy, Dialectic Behaviour Therapy are used, specify the skills introduced or the therapeutic themes of the session
• Describe any ideas, concepts or frameworks that were introduced, or the content of any handouts or use of whiteboard

Risk Assessment and Management:

• Suicidal Ideation: Describe in detail any history of suicidal ideation, attempts, plans
• Homicidal Ideation: Describe any homicidal ideation
• Self-harm: Detail any history of self-harm
• Violence & Aggression: Describe any recent or past incidents of violence or aggression
• Addictive Behaviours: Detail any recent or past addictive behaviours
• Risk-taking/Impulsivity: Describe any risk-taking behaviors or impulsivity
• Management Plan: Describe strategy or steps taken to manage above (if applicable)

Next Steps:

• Next Session: Date and time of next session. Note any plans for next session
• Assigned Homework: Any tasks or activities assigned to the client