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Run: Individual Therapy Progress Note

An individual therapy progress note template for documenting session details, interventions, patient response, risk screening, and next steps in one payer-re...

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Session Details

Session date (required)

Date the individual therapy session occurred.

Start time (required)

Time the session began.

Session duration (minutes) (required)

Total face-to-face or telehealth session time in minutes.

Service modality (required)

Select how the session was delivered.

Provider name (required)

Clinician completing the note.

Location

Optional service location if needed for the record.

Clinical Context

Primary diagnosis (required)

Diagnosis relevant to this session note. Use the minimum necessary detail required for clinical documentation.

Targeted treatment plan objective (required)

State the specific treatment plan objective addressed in this session.

Presenting concerns / current status (required)

Briefly describe the patient's current symptoms, concerns, or status at the start of the session.

Symptom change since last visit (required)

Select the overall change observed or reported since the prior session.

Interventions and Patient Response

Interventions used (required)

Select all interventions delivered during the session.

Intervention details (required)

Describe the intervention content, techniques used, and any relevant clinical observations.

Patient participation (required)

Select the level of participation during the session.

Patient response (required)

Document the patient's response to interventions, including insight, affect, behavior, and any reported benefit.

Risk, Safety, and Progress

Risk screening completed (required)

Indicate whether risk or safety screening was completed during this session.

Current risk level

Select the current risk level if assessed.

Progress toward objective (required)

Select the overall progress toward the targeted treatment plan objective.

Progress summary (required)

Summarize evidence of progress, barriers, and how the session supports the treatment plan.

Plan and Follow-Up

Next steps (required)

Describe the plan for the next session, homework, referrals, or care coordination.

Follow-up date

Optional date for the next appointment or follow-up.

Additional notes

Use for any other clinically relevant information not captured elsewhere.

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