15 Free Mental Health Progress Note Templates & Examples

Mental health progress Notes encompass information about counseling sessions, medication administration, evaluations of pertinent symptoms, treatment strategies, and noteworthy modifications in the patient's state over time.

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15 Free Mental Health Progress Note Templates (with Examples)

Example 1: Custom Format Therapy Progress Note Example

Initial Assessment

Client Information:

Client Name: Sarah Jones (confidential)

Date of Birth: 1985-05-12

Referral Source: Self

Presenting Concerns:

Sarah, a 37-year-old marketing professional, presents for the first time reporting feeling overwhelmed and anxious for the past 6 months. She describes a constant feeling of worry and difficulty concentrating, making it hard to focus on work tasks. Sarah says she has trouble sleeping through the night, often waking up feeling tired and on edge. These symptoms have significantly impacted her ability to manage her workload and maintain a healthy work-life balance.

History of Present Illness:

Sarah describes the anxiety gradually increasing over the past 6 months, coinciding with a demanding new project at work. She feels pressure to perform well and constantly worries about meeting deadlines. She admits to neglecting self-care activities like exercise and social outings due to feeling overwhelmed. Sarah has tried relaxation techniques like deep breathing exercises with limited success.

Past Medical History:

No significant past medical history reported.

Psychiatric History:

No prior history of mental health diagnoses or treatment.

Social History:

Sarah is married with no children. She lives with her husband in a suburban area. She describes her relationship with her husband as supportive but feels hesitant to burden him with her worries. Sarah has a close circle of friends but has been isolating herself due to feeling drained and anxious.

Family History:

No significant family history of mental health conditions reported.

Mental Status Examination:

Sarah appears well-groomed and dressed appropriately. Her mood is described as anxious and worried. She speaks rapidly with a pressured speech pattern. Thought processes appear logical with no evidence of delusions or hallucinations. Sarah denies suicidal ideation but admits to feeling hopeless at times.

Assessment (Preliminary):

Based on the information gathered, a preliminary diagnosis of Generalized Anxiety Disorder (GAD) is considered (DSM-5 code: 300.02 [optional]). However, further assessment may be needed to rule out other potential diagnoses.

Treatment Plan:

A collaborative treatment plan was developed with Sarah, focusing on:

Goals of Therapy: Reduce anxiety symptoms, improve sleep quality, and enhance coping skills for managing work-related stress.

Interventions: Cognitive Behavioral Therapy (CBT) techniques will be used to identify and challenge negative thought patterns contributing to anxiety. Relaxation training strategies will be introduced to promote better sleep hygiene and manage stress levels.

Frequency of Sessions: Weekly sessions are recommended initially, with the possibility of adjusting the frequency as therapy progresses.

Homework Assignments: Sarah will be encouraged to practice relaxation techniques daily and monitor her sleep patterns.

Referral to Other Providers (optional): At this time, referral to a psychiatrist for medication management is not considered necessary. However, this will be re-evaluated if deemed necessary during the course of therapy.

Disposition:

Sarah agreed to schedule weekly therapy sessions and was provided with resources on CBT and relaxation techniques.The next session will focus on further exploring Sarah's negative thought patterns related to work stress and begin implementing relaxation training exercises.

Additional Notes:

Sarah seemed motivated to engage in therapy and expressed interest in learning coping mechanisms to manage her anxiety.

 

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Example 2: SOAP Note Example

Crisis Intervention

Client: John Doe (confidential) Date: 2024-07-22

Subjective (S):

Presenting Concern (PC): John, a 25-year-old male, was brought to the emergency department by his friend after expressing suicidal ideation. John reported feeling hopeless and overwhelmed by financial difficulties and a recent breakup. He stated he had a plan to overdose on medication he found at home.

History of Present Illness (HPI): John has been struggling with depression for the past year but has not sought professional help. He recently lost his job due to company downsizing and ended a long-term relationship. These events exacerbated his feelings of hopelessness and isolation.

Mental Status Exam (MSE): John appeared tearful and disheveled. His mood was depressed, and his affect was blunted. Speech was slow and low-toned. He denied auditory or visual hallucinations but endorsed feelings of worthlessness and guilt. John confirmed current suicidal ideation with a specific plan and access to means.

Objective (O):

Vital Signs: Within normal limits.

Mental Status Exam (if not included in Subjective): Same as above.

Assessment (A):

Impression: Major Depressive Disorder, Single Episode, Severe with Suicidal Ideation (DSM-5 code: 296.24 [optional]).

Risk Assessment: High suicide risk due to specific plan and means available.

Plan (P):

Safety Measures: John's friend was instructed to stay with him until a safety plan could be established. All medications were removed from his possession.

Disposition: Admission to the inpatient psychiatric unit for further evaluation, crisis stabilization, and development of a comprehensive treatment plan.

Treatment Plan (to be further developed in inpatient setting): Medication evaluation by a psychiatrist,individual therapy sessions focusing on mood regulation and coping skills, and psychoeducation about depression.

Follow-up: Referral information for outpatient mental health services will be provided upon discharge.

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Example 9: PIE Note Template

Client: John Doe Date: April 15, 2024 Therapist: Dr. Jane Smith

Problem: 

Client reported increased anxiety related to upcoming job interview.

Intervention: 

Engaged in deep breathing exercises to manage immediate anxiety. Utilized cognitive restructuring to challenge negative thought patterns about the interview. Role-played potential interview questions to build confidence.Developed a coping plan for anxiety during the interview.

Evaluation: 

Client reported decreased anxiety levels following deep breathing exercises. Demonstrated improved confidence and fluency during role-playing. Identified several negative thought patterns related to the interview and began to challenge their validity. Client expressed a sense of preparedness and developed a concrete coping plan.

Key Points:

Problem: Clearly states the primary issue addressed in the session.

Intervention: Outlines specific therapeutic techniques used.

Evaluation: Describes the client's response to the intervention.

Note: This is a simplified example. Actual PIE notes may include additional details, such as specific goals, treatment plans, and progress toward outcomes.

Example 10: Play Therapy Note Template

Client: Emily Smith Age: 6 Date: April 15, 2024 Therapist: Dr. Sarah Johnson

Child's Behavior

Mood: Initially appeared withdrawn, gradually became more engaged.

Play Themes: Primarily engaged in aggressive play with action figures, depicting conflict and rescue scenarios.

Verbalizations: Expressed feelings of anger and frustration through character voices.

Therapist Interventions

Reflection: Reflected child's emotions and actions, validating feelings.

Limit Setting: Provided clear and consistent boundaries during aggressive play.

Directive Play: Introduced calming activities like building with blocks and drawing.

Observations and Interpretations

Emily appears to be processing anger and frustration related to a recent family conflict.

Aggressive play may be a coping mechanism for overwhelming emotions.

There is potential for increased self-regulation and emotional expression through continued therapy.

Goals for Next Session

Encourage exploration of alternative coping mechanisms.

Expand on themes of problem-solving and conflict resolution through play.

Strengthen therapeutic relationship and build trust.

Additional Notes

Parent reported increased irritability at home.

Collaborative treatment plan discussed with parent.

Note: This is a basic example. Play therapy notes often include detailed descriptions of play activities, nonverbal cues,and symbolic meaning. It's essential to document the child's emotional state, behavioral changes, and progress towards therapeutic goals. 

Recommended Reading: Anxiety Disorder Templates for Clear Medical Documentation 

 

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Example 11: Group Therapy Note

Group: Anxiety Management Date: April 15, 2024 Therapist: Dr. Emily Carter

Group Members Present: Alex, Ben, Chris, Danielle, Emily

Group Focus: 

Managing anxiety in social situations

Group Process: 

The group began by sharing experiences of social anxiety. Alex described feeling overwhelmed at parties, while Danielle expressed difficulty initiating conversations. Members engaged in active listening and offered empathy.

The group explored cognitive-behavioral techniques for managing anxiety, including identifying negative thought patterns and challenging them. Chris shared a personal example of how cognitive restructuring helped him overcome fear of public speaking.A role-playing exercise was conducted to practice social skills. Members took turns initiating conversations and providing supportive feedback. Emily expressed increased confidence after the exercise.

Group Dynamics: 

The group atmosphere was supportive and collaborative. Members shared personal experiences openly. Some members exhibited increased comfort with vulnerability as the session progressed.

Therapist Interventions: 

Facilitated group discussion, modeled active listening, provided psychoeducation on anxiety management techniques, and offered individual support and encouragement.

Group Goals: 

Continue to develop social skills, practice coping strategies, and build support within the group. Encourage members to apply learned skills in real-life situations.

 

Note: This is a basic example. Group therapy notes may include more specific details about individual members, such as presenting problems, treatment goals, and progress. It's also important to document any significant events or challenges that occurred during the session.

 

 

Example 12: Progress Note For ADHD

Client: Alex Turner, Age: 10

Date: 07/25/2024

Subjective: 

Alex reports increased difficulty completing homework assignments. He describes feeling overwhelmed and easily distracted. His mother reports increased conflicts related to chores and daily routines.

Objective: 

Alex appeared fidgety and restless during the session. He had difficulty maintaining focus on the conversation and frequently shifted his attention to external stimuli.

Assessment: 

Alex continues to exhibit symptoms of inattention and impulsivity consistent with ADHD. Despite medication management, challenges persist in completing tasks and managing time effectively.

Plan:

Introduce time management strategies, such as breaking down tasks into smaller steps and using visual aids.

Teach self-monitoring techniques to help Alex identify personal triggers for inattention and develop coping strategies.

Collaborate with the school to implement accommodations in the classroom, such as extended time for assignments and a quiet workspace.

Schedule a follow-up appointment in two weeks to assess progress and make adjustments to the treatment plan as needed.

 

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Example 13: Discharge Summary For Major Depressive Disorder

Patient Name: Sarah Johnson Date of Birth: 05/12/1985 Admission Date: 07/15/2024 

Discharge Date: 07/25/2024Attending Physician: Dr. Alex Turner

Reason for Admission: 

Major Depressive Disorder with suicidal ideation.

Summary of Hospital Course:

Sarah presented with a two-week history of severe depressive symptoms, including anhedonia, insomnia, decreased appetite, and suicidal ideation. Upon admission, a comprehensive psychiatric evaluation was conducted, and a diagnosis of Major Depressive Disorder was confirmed.

During her hospitalization, Sarah participated in individual and group therapy sessions focusing on cognitive-behavioral techniques, mood management, and interpersonal skills. She also received medication management with [medication name] and demonstrated a positive response to treatment. Suicidal ideation resolved with the initiation of treatment.

Discharge Diagnosis: 

Major Depressive Disorder, in partial remission.

Discharge Medications:

[Medication name] [dosage] PO daily

[Medication name] [dosage] PRN for insomnia

Discharge Instructions:

Continue with prescribed medications as directed.

Schedule a follow-up appointment with primary care provider and mental health professional within two weeks of discharge.

Continue with recommended psychotherapy sessions.

Monitor for any return of depressive symptoms or suicidal ideation.

Contact mental health professional or primary care provider immediately if symptoms worsen or new symptoms develop.

Discharge Disposition: 

Discharged home with follow-up appointments scheduled.

Note: This is a simplified example and does not include all potential elements of a discharge summary. A complete discharge summary should include additional information such as patient demographics, social history, physical exam findings, laboratory results, and any consultations with other specialists.

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Example 14: Medication Management 

Patient: John Doe Date: 07/25/2024

Subjective (S):

Patient reports increased anxiety and difficulty concentrating despite being on medication. He states that he has been taking Sertraline 100mg daily for the past 6 months with minimal improvement. He expresses concerns about potential side effects and lack of motivation.

Objective (O):

Patient appears anxious and fidgety. Vital signs within normal limits. No evidence of significant side effects noted.

Assessment (A):

Patient exhibits continued symptoms of anxiety despite adequate trial of Sertraline. Potential need for medication optimization or augmentation.

Plan (P):

Increase Sertraline dosage to 150mg daily for 2 weeks.

Re-evaluate symptoms in 2 weeks.

Consider adding adjunctive medication (e.g., buspirone) if symptoms persist.

Explore the potential for psychotherapy to address underlying anxiety triggers and coping mechanisms.

Educate patient on the importance of medication adherence and potential side effects.

 

Note: This is a simplified example and does not include all potential elements of a medication management SOAP note. A complete note would include additional information such as patient demographics, medical history, and other relevant medications.

 

 

Example 15: S10.AI’s Extended Progress Note

Client with Anxiety and Physical Symptoms

Client: John Doe

Date: 07/25/2024

Subjective (S):

Client presents with complaints of chronic neck and back pain, difficulty relaxing, and feelings of overwhelming anxiety.He describes a "jelly-like" sensation in his body and difficulty finding a comfortable position. John reports feeling tired,down, and frustrated due to his son's financial struggles. He has experienced age-related anxiety and the impact of a recent fall has exacerbated his physical discomfort. These issues have significantly impacted his daily life and functioning.

Objective (O):

Client appears tense and restless during the session. He exhibits guarded body language and limited eye contact.

Assessment (A):

Client presents with symptoms consistent with generalized anxiety disorder (GAD), characterized by excessive worry,physical tension, and sleep disturbances. The physical symptoms, including neck and back pain, may be related to chronic muscle tension associated with anxiety. The client's age-related concerns and recent fall have contributed to a sense of vulnerability and increased anxiety.

Plan (P):

Continue exploring the relationship between anxiety and physical symptoms.

Introduce progressive muscle relaxation and mindfulness techniques to manage physical tension.

Encourage regular physical activity to improve mood and reduce muscle tension.

Explore potential referrals for physical therapy if needed.

Develop a coping strategy for dealing with financial concerns and the son's situation.

Address the client's age-related anxieties through cognitive-behavioral techniques to challenge negative thought patterns.

Schedule a follow-up appointment to monitor progress and adjust treatment plan as needed.

 

Note: This SOAP note provides a concise overview of the client's presenting problems, assessment, and treatment plan. It incorporates both psychological and physical symptoms, as well as considering the client's overall well-being.