Couples Therapy Progress Note (US)
Session Note Template:
A standard couples therapy progress note that can be used to support CPT code (90847, 90846), typically for ongoing couples psychotherapy sessions when both or only one party is present. It covers the couple and individual perspectives for presenting concerns, relationship interactions/dynamics, risk assessment, MSE, practice assignments, and treatment goals progress, with identification of evidence-based interventions used, any clinical assessments administered, and plan/recommended follow-up. It includes framing around the primary client (determined by client name line or specified by clinician) for treatment plan, progress, and diagnosis to contextualize presenting concerns, and may be used for insurance billing purposes. It can leverage previous sessions or documents including the treatment plan where indicated to evidence support for ongoing treatment and connect the clinical narrative.
For a full couples therapy intake and assessment, consider using the companion template Relationship Therapy Intake Assessment.
Use this template in NovoNote, NovoPsych’s AI scribe for mental health clinicians.
Primary Client: Name of the client whose insurance the session is billed under.
Diagnosis: Primary client’s diagnosis (diagnoses) with DSM-5-TR and ICD-10-CM codes
Partner (Secondary Client): First name of the partner.
Attendance: Who attended (one or both partners), location if stated, and any part of the session where one partner met with the clinician alone.
Presenting Concerns
- Primary relationship concerns and life stressors raised this session, by the partner and the couple
- Impact on daily functioning and the relationship
- Updates since last session, including practices completed and the response
Session Content
- Main issues and significant patterns discussed
- Link to treatment goals, using treatment plan wording where a treatment plan is provided
Relational Dynamics and Couple Interaction
- Interaction patterns such as communication, conflict, support, repair, and problem-solving, for the partner and the couple
- Any clinician explanation of patterns using an evidence-based framework (e.g., Gottman, EFT, CBT, family systems)
Interventions and Response
“Not documented” printed for domains where no content is recorded
- Named interventions, techniques, or models used, including psychoeducation, role-play, exercises, or worksheets
- Each partner’s response to the interventions
Individual Client Observations
Primary Client
Mental Status Exam
- Appearance: Grooming, dress and physical presentation as observed
- Behavior: Activity level, cooperation, eye contact and any notable behaviors as observed
- Speech: Rate, rhythm, volume and tone as observed
- Mood: Patient’s reported mood, using their own words where possible
- Affect: Range, congruence and appropriateness as observed
- Thought Process: Organization, coherence and goal-direction
- Thought Content: Preoccupations, delusions and intrusive thoughts
- Perception: Any reported hallucinations or sensory misinterpretations, with type and impact
- Cognition: Memory, orientation, concentration and comprehension
- Insight: Patient’s understanding of their own condition and treatment
- Judgment: Decision-making ability and understanding of consequences
Symptoms
- List symptoms reported and named by client clinically relevant to session content and primary client’s diagnosis
Secondary Client
Mental Status Exam
- Same as MSE items above
Symptoms
- Same as symptom description above
Risk Assessment
Each item is labeled by who disclosed it and if partner was present
- Suicidal ideation, self-harm, homicidal ideation or harm to others, and violence and aggression, including pertinent negatives
- Intimate partner violence in either direction, and any other risk (e.g., child, elder, or dependent adult abuse or neglect)
- Access to means, warning signs, and protective factors
- Risk management, including safety planning and crisis resources such as 988 and 911
Treatment Progress
- Primary client’s progress toward treatment goals (e.g., advancing, plateauing, regressing)
- Primary client’s treatment plan, where contextual notes, source content or document provides it
- Couple’s progress on presenting concerns
Clinical Assessments
- Measures administered, scores, prior scores, and the clinician’s interpretation and effect on treatment
Psychiatric Medication
- Medication name, dose, frequency, adherence, and recent changes for each partner when applicable
Coordination of Care
- Contact with other providers, information shared, and consent obtained, noting which client it relates to
Practices Assigned
- Tasks, skills, or practices to complete before next session, labeled with who will complete them and any resources provided
Plan and Next Steps
- Focus for the next session
- Internal and external referrals, noting which client they are for and current status
- Session frequency, any changes, and expected length of care, where stated
Primary Client: Mary Blogs
Diagnosis: Adjustment disorder with mixed anxiety and depressed mood (DSM-5-TR; ICD-10-CM F43.23)
Partner (Secondary Client): Tom
Attendance: Mary and Tom attended together in person for the full session.
Presenting Concerns
- Mary reported increased conflict with Tom since his job loss in August, with frequent arguments about finances and household tasks.
- Mary described worry, low mood, and poor sleep, stating the conflict leaves her “on edge all the time”; she reported these symptoms are affecting her concentration at work.
- Tom reported feeling “criticized” and withdrawing to avoid arguments (Tom).
- Update since last session: the couple completed two of three planned weekly check-ins; both reported the check-ins were calmer than usual.
Session Content
- Reviewed the couple’s most recent argument about a credit card bill, which escalated and ended with Tom leaving the house for several hours.
- Linked the conflict pattern to Mary’s treatment goal of reducing anxiety symptoms related to relationship stress.
- Explored how financial strain has reduced shared time and positive interactions.
Relational Dynamics and Couple Interaction
- Pursue–withdraw pattern: Mary raises concerns with urgency and criticism (“you never follow through”); Tom responds by shutting down and leaving.
- Repair attempts are present but often missed; Tom described sending Mary a text apology that she did not see as sincere.
- Clinician identified criticism and stonewalling as two of Gottman’s “Four Horsemen” and explained their impact on relationship satisfaction.
Interventions and Response
- Gottman-informed psychoeducation on the Four Horsemen and their antidotes.
- Practiced gentle start-up using an “I feel… about… I need…” format; Mary rephrased a concern about the bill with clinician coaching.
- Introduced self-soothing breaks of 20 minutes when either partner feels flooded.
- Response: both partners engaged; Mary reported the gentle start-up “felt awkward but less attacking,” and Tom agreed to try taking a break rather than leaving without explanation.
Individual Client Observations
Primary Client (Mary)
Mental Status Exam
- Appearance: Casually dressed, well-groomed
- Behavior: Cooperative, good eye contact
- Speech: Normal rate; volume increased when discussing finances
- Mood: “Stressed and tired”
- Affect: Anxious, congruent with reported mood
- Thought Process: Logical and goal-directed
- Thought Content: Preoccupied with financial concerns; no delusions
- Perception: Not documented
- Cognition: Reports reduced concentration at work
- Insight: Good; recognizes her criticism escalates conflict
- Judgment: Intact
Symptoms
- Excessive worry, low mood, difficulty falling asleep, reduced concentration, irritability
Partner (Secondary Client) (Tom)
Mental Status Exam
- Appearance: Casually dressed
- Behavior: Initially guarded, more engaged later in session
- Speech: Quiet, normal rate
- Mood: “Frustrated”
- Affect: Restricted, congruent
- Thought Process: Logical
- Thought Content: Focused on job search and feeling blamed
- Perception: Not documented
- Cognition: Not documented
- Insight: Fair; acknowledges withdrawing during conflict
- Judgment: Intact
Symptoms
- Reports feeling “useless” since job loss and reduced motivation
Risk Assessment
- Suicidal Ideation: Mary and Tom each denied current or past suicidal ideation when asked, with both present.
- Self-Harm: Both denied self-harm urges or behavior.
- Homicidal Ideation or Harm to Others: Both denied.
- Violence and Aggression: Both denied physical aggression; Mary reported arguments involve raised voices.
- Intimate Partner Violence: Both denied physical, sexual, or coercive behavior in the relationship when asked.
- Access to Means: Tom confirmed no firearms in the home.
- Warning Signs: Mary reported worsening sleep over the past two weeks.
- Protective Factors: Commitment to the relationship, engagement in treatment, support from Mary’s sister.
- Risk Management: Clinician reviewed 988 Suicide & Crisis Lifeline and 911 for emergencies; both partners acknowledged.
Treatment Progress
- Primary Client: Advancing progress toward reducing anxiety related to relationship stress; Mary reports fewer escalated arguments (two this week, down from four).
- Couples: Some improvement; weekly check-ins are reducing conflict, though the pursue–withdraw pattern remains active.
Clinical Assessments
- Couples Satisfaction Index (CSI-16): Mary – 42, Tom – 45 (previous: Mary – 38, Tom – 41); clinician noted scores remain in the distressed range but are improving, supporting continued focus on communication skills.
- Generalized Anxiety Disorder 7-Item Scale (GAD-7): Mary – 12 (previous 14), moderate range.
Practices Assigned
- Couple: Continue weekly 30-minute check-ins on Sunday evenings.
- Mary: Use gentle start-up when raising at least one concern this week.
- Tom: Use a 20-minute break and state when he will return, rather than leaving.
Plan and Next Steps
- Next session to focus on building positive interactions and reviewing use of breaks.
- Mary to consider individual therapy for sleep and anxiety; clinician to provide referral options.
- Continue weekly couples sessions; next session scheduled for October 14, 2026 at 5:00 pm.
- Template Type
- Session Note
Author:
Dr Liz Rojas
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