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Run: Case Notes and Progress Note Form

Case Notes and Progress Note Form template for documenting client contacts, services provided, observations, and next steps in a defensible case record. Use ...

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Note Identification

Date of Contact / Service (required)

The actual date the interaction or service occurred — not the date this note is being written.

Time of Contact (required)

Start time of the interaction.

Case Manager / Author Name (required)

Title / Credential (required)

Client / Case ID (required)

Use the assigned case number. Do NOT enter the client's full name or SSN in this field.

Program / Service Line (required)

Contact Details

Type of Contact (required)

Location / Setting

Duration of Contact (minutes) (required)

Billable and non-billable time combined. Enter whole minutes.

Participants Present (required)

Select all who participated in this contact.

Was an interpreter used? (required)

Language Interpreted

Presenting Situation and Observations

Client Presentation / Affect (required)

Select all descriptors that apply based on direct observation during this contact.

Reason for Contact / Presenting Issue (required)

Briefly describe the purpose of this contact or the issue the client raised. Use the client's own words where appropriate (use quotation marks).

Safety Concerns Identified (required)

Includes risk of harm to self, harm to others, domestic violence, child/elder abuse, housing instability, or food insecurity.

Safety Concern Description and Action Taken

Describe the concern, your assessment, and any mandatory reporting or safety planning actions taken. Reference applicable policy (e.g., mandated reporter obligation under state statute).

Services Provided and Interventions

Services / Interventions Provided (required)

Narrative Description of Services (required)

Provide a clear, factual narrative of what was done, discussed, or decided. Write in past tense. Avoid jargon. This is the core of the defensible progress note.

Referrals Made This Contact

List any referrals initiated during this contact.

Client Response to Services / Interventions (required)

Progress Toward Goals and Next Steps

Progress Toward Care Plan Goals (required)

Barriers to Progress Identified

Select all barriers observed or reported during this contact.

Action Steps for Client

List specific, measurable tasks the client agreed to complete before the next contact.

Action Steps for Case Manager (required)

List specific follow-up tasks you will complete. Include target dates where applicable.

Scheduled Follow-Up Date

Date of next planned contact or check-in with client.

Current Case Status (required)

Supervisor Review and Attestation

Is supervisory review required for this note? (required)

Supervisor Name

Supervisor Comments

Author Attestation (required)

By checking this box, you attest that the information in this progress note is accurate, complete to the best of your knowledge, and was documented in accordance with your organization's documentation policy and applicable professional standards (CMSA Standards of Practice; NASW Code of Ethics).

Yes No N/A

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