Individual Therapy Progress Note (US)
Session Note Template:
A standard therapy progress note that can be used to support CPT codes 90834 and 90837, typically for follow-up individual psychotherapy sessions by licensed mental health professionals (clinical psychologists, clinical social workers, professional counselors). It covers session focus, current symptoms, interventions, response, risk assessment, relevant psychiatric history, clinical summary and progress, and plan. It can leverage previous sessions or documents including the treatment plan where indicated to evidence support for ongoing treatment and connect the clinical narrative. This template runs in NovoNote, NovoPsych’s AI scribe for clinicians.
Template Structure
Example Output
Template Structure
Presenting Concern
- Client’s main concern and any current stressors or triggers the client identified, summarized concisely in their own words
Current Symptoms
- Symptoms, as described by the client and asked about by the clinician, with onset, frequency, duration, severity, any subjective rating the client gave, and any changes since last session
- Impact on day-to-day functioning, with specific details and examples, using the client’s own words where stated
- Any reference to previous session practices and the client’s response to them
Mental Status Examination
“Not observed” printed for domains where no content is recorded
- Appearance: grooming, dress and presentation as observed
- Behavior: activity level, interaction with surroundings, and notable behaviors explicitly evidenced in session
- Speech: pace noted only where fast (201+ words per minute) or slow (under 129), with any notable volume, fluency or rhythm
- Mood: the client’s self-described emotional state, in their own words
- Affect: range and appropriateness of emotional expression, including any discrepancy with stated mood
- Thoughts: thought process and content, with suicidal and homicidal ideation cross-referenced to Risk Assessment rather than repeated
- Perceptions: reported hallucinations or sensory misinterpretations, with type and impact
- Cognition: orientation, attention, concentration or memory findings the session documents
- Insight: awareness of condition and understanding of the need for treatment
- Judgment: capacity to make sound decisions and understanding of consequences
Therapeutic Interventions & Response
- Therapist Interventions: the evidence-based interventions used (for example CBT, behavioral activation, motivational interviewing, DBT, EMDR), what each targeted, and any psychoeducation provided
- Client Response: engagement, understanding, resistance, insight, emotional response during the work, and skills practiced in session; where a subjective rating was given before and after an in-session exercise, both ratings and the change are recorded
Risk Assessment
“Not observed” printed for domains where no content is recorded
- Suicidal Ideation: presence, frequency, intensity, intent, plan, means access, preparatory behavior, deterrents, and any instrument used
- Homicidal Ideation and Risk to Others: ideation, identified targets, intent, plan, means access
- Self-Harm: current and historical non-suicidal self-injury
- Access to Lethal Means: firearms, medications, other means, and any steps discussed to reduce access
- Risk Formulation and Management: the clinician’s formulation in their own words, risk and protective factors noted, and any step taken this session such as safety planning, a level-of-care decision, follow-up interval, or collateral involvement
Psychiatric Medication and History
- Psychiatric Diagnoses: name and details of any psychiatric diagnoses
- Current Medications: current medications with dose and frequency, and any recent changes
- Current Medical Issues: recent medical issues, treatment or hospitalization, and outcome
Clinical Assessments
- Brief interpretation of the scores and any change in scores when available
- A “Summary of Scores” table with the columns Measure, Date, Domain, Score and Severity Band
Clinical Summary & Progress
- Short formulation of what is happening for the client and why, drawing on presenting symptoms, functional impairment and mental status findings, including precipitating or maintaining factors identified
- Why continued treatment, frequency, and approach or any change, is clinically indicated, drawing on the symptoms, impairment, measures and goals
- Diagnosis: the diagnosis(es) named, with DSM-5-TR and ICD-10-CM codes, and any rule-out and differentials named, when evidenced with supporting content; otherwise “No diagnosis stated this session” is printed
- Treatment Plan: active goals and objectives from session content and additional contextual sources, including the treatment plan where it appears from earlier session records or documents
- Treatment Goal Addressed: the goal(s) the session targeted, using the client’s own words and clinician language when stated, or marked as inferred from session focus
- Progress Toward Goals: 1–2 sentences tying progress to the symptoms, impairment and scores recorded above
- Progress Rating: Goal Met / Achieving / Some Progress / Maintaining / Loss / Not Addressed
Plan & Next Steps
- Practices Assigned: collaboratively agreed between-session tasks with frequency and timing where stated
- Referrals & Coordination: any referral, coordination with another provider, medication concern for a prescriber, or treatment plan review due when mentioned
- Next Session: session frequency where stated or evidenced, date/time when mentioned
Example Output
Presenting Concern
Mary Blogs reported that she is “running on empty and waiting for the next thing to go wrong,” describing persistent worry that has intensified over the past two months. She identified stressors: a team restructure at work announced six weeks ago, an increased caseload after two colleagues left, and ongoing conflict with her sister about their mother’s care.
Current Symptoms
- Generalized worry, present most days for approximately four months and worsening over the last six weeks; rated 7/10 at its worst this week.
- Initial insomnia, 4–5 nights per week, taking 60–90 minutes to fall asleep; reports waking unrefreshed.
- Muscle tension in shoulders and jaw, described as “constant,” tension headaches, and two short episodes of rapid heart rate and shortness of breath while driving.
- Concentration difficulty at work, requiring her to re-read documents several times.
- Reported improvement in irritability since last session, which she attributed to “getting out of the house on the weekend.”
- Functional impact: has stopped attending her Thursday evening running group (four weeks), declined two social invitations, and is taking work home most evenings.
- Previous session practice: completed the thought record on three occasions and reported it was “easier to spot the catastrophizing once it was on paper,” but not consistent when overwhelmed.
Mental Status Examination
- Appearance: Casually dressed, well groomed, appeared her stated age.
- Behavior: Cooperative and engaged throughout; shifted position frequently in the chair.
- Speech: Normal rate, volume and fluency.
- Mood: “Wound up, and tired underneath it.”
- Affect: Anxious, congruent with stated mood, with reactive range during discussion of work.
- Thoughts: Linear and goal-directed. Content dominated by anticipatory worry about job security and caregiving obligations. No delusional content. Ideation addressed in Risk Assessment.
- Perceptions: No hallucinations or perceptual disturbance reported.
- Cognition: Alert and oriented; attention adequate for the session; self-reported concentration difficulty as noted above.
- Insight: Good; recognizes avoidance is maintaining her distress.
- Judgment: Intact; decision-making appropriate to circumstances.
Therapeutic Interventions & Response
- Therapist Interventions: Cognitive restructuring, examining evidence and generating a balanced alternative. Behavioral activation to return to the running group. Psychoeducation provided on the physiology of the panic response and on sleep hygiene.
- Client Response: Engaged readily and generated the balanced thought with minimal prompting. Tearful when discussing her mother’s care, and recovered within the session. Voiced some hesitation about the running group, addressed with problem-solving. Practiced diaphragmatic breathing in session and reported reduced anxiety.
Risk Assessment
- Suicidal Ideation: Denied — “no, nothing like that.”
- Homicidal Ideation and Risk to Others: Denied.
- Self-Harm: Denied.
- Access to Lethal Means: Not observed.
- Risk Formulation and Management: No emergent risk concerns or change in risk. Endorses protective factors: strong therapeutic engagement, stable employment to date, no ideation on direct questioning, and an active partner relationship. Aware of crisis resources and how to use them (988 Suicide & Crisis Lifeline or 911, or present to the nearest emergency department).
Clinical Assessments
GAD-7 administered at the start of the session. The score falls in the moderate range and is 2 points lower than at intake, a change that is consistent with her reported improvement in irritability but not yet clinically meaningful.
| Measure | Date | Domain | Score | Severity Band |
| GAD-7 | 9/14/2026 | Generalized anxiety | 13 | Moderate |
| GAD-7 | 8/17/2026 | Generalized anxiety | 15 | Moderate |
Clinical Summary & Progress
Mary presents with moderate generalized anxiety precipitated by workplace restructure and caregiving conflict, maintained by catastrophic appraisals of job loss and by avoidance of exercise and social contact. Continued treatment is indicated given a GAD-7 of 13, ongoing sleep disruption and withdrawal from valued activity; the clinician recommended weekly CBT sessions to consolidate cognitive restructuring while behavioral activation is established.
- Diagnosis: Generalized Anxiety Disorder evidenced by symptoms consistent with DSM-5-TR / ICD-10-CM F41.1. Rule out Panic Disorder given the two discrete episodes while driving; clinician to continue to monitor.
- Treatment Plan: Goal 1 — reduce anxiety symptoms to the mild range on the GAD-7. Goal 2 — resume regular physical activity and social contact.
- Treatment Goal Addressed: “Getting my head to stop running the worst-case scenario,” and resuming the running group.
- Progress Toward Goals: Some movement on Goal 1, 2-point GAD-7 reduction. Goal 2 has not progressed, with increased avoidance.
- Progress Rating: Some Progress
Plan & Next Steps
- Practices Assigned: Complete the thought record 4x, at least 1x when distress is high. Attend running group once this week. Stop work-related tasks by 8:00 pm on weeknights.
- Referrals & Coordination: Clinician to consider a primary care referral for review of tension headaches if they persist.
- Next Session: Review of the running group attempt and continued cognitive restructuring around job security. Weekly sessions to continue. Scheduled for Monday, September 21, 2026 at 2:30 pm.
- Template Type
- Session Note
- Therapy Session
Author:
Dr Liz Rojas
Clinical Psychologist & Research Fellow
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