-> Download PIE Note Checklist and Guidelines for Mental Health Documentation by completing the form.

What is a PIE Note?

A PIE note is a documentation method used by mental health professionals to record client interactions efficiently. Its brevity and simplicity make it a popular choice, though insurance providers typically do not mandate a specific format. The PIE acronym stands for three key sections:

Problem (P): This section outlines the client’s presenting issue or reason for seeking therapy. It may include relevant mental health diagnoses, symptoms, or specific concerns driving the session.

Intervention (I): Describes the actions taken by the clinician to address the client’s problem, such as therapeutic techniques, psychoeducation, or coping strategies provided.

Evaluation (E): Assesses the client’s response to the interventions, noting their receptiveness, progress, or areas requiring further attention. It may also include next steps for the client or clinician.

PIE Note Template for Mental Health Documentation

Date: [Insert Date, e.g., MM/DD/YYYY]

Client Name: [Insert Full Name]

Case/Concern: [Insert Primary Issue, e.g., Anxiety, Depression]

Clinician: [Insert Name and Credentials, e.g., Jane Smith, LCSW]

Location of Service: [Insert Location, e.g., Office, Virtual]

Duration of Session: [Insert Time, e.g., 50 minutes]

PIE Note

Problem (P)

[Describe the client’s presenting issue or reason for the session, using client’s or caregiver’s words when possible]

[Include relevant mental health diagnoses, symptoms, or concerns (e.g., frequency, duration, intensity)]

[Note any contextual factors, such as recent stressors or triggers]

Intervention (I)

[List specific actions taken by the clinician to address the problem (e.g., therapeutic techniques, psychoeducation, coping strategies)]

[Specify tools or approaches used (e.g., CBT, mindfulness exercises)]

[Note any referrals or resources provided]

Evaluation (E)

[Assess the client’s response to interventions (e.g., level of engagement, reported effectiveness)]

[Note progress, setbacks, or areas for further monitoring]

[Outline next steps for the client or clinician (e.g., homework, follow-up plans)]

Additional Notes

[Include any relevant observations, such as safety concerns, legal/ethical discussions, or consultations with other providers]

[Document client strengths or resources observed during the session]

Signature: [Clinician’s Name and Credentials]

Date Signed: [MM/DD/YYYY]

Example PIE Note for Mental Health Documentation

Date: 06/18/2025

Client Name: Marcus Lee

Case/Concern: Generalized Anxiety

Clinician: Rachel Carter, LCSW

Location of Service: Virtual Session (Telehealth)

Duration of Session: 45 minutes

PIE Note

Problem (P)

Marcus, a 32-year-old male, reported feeling “constantly nervous” about work deadlines and social interactions. He described frequent racing thoughts and difficulty concentrating, noting symptoms have intensified over the past month due to a recent promotion. He mentioned occasional physical symptoms, including tightness in his chest.

Intervention (I)

Provided psychoeducation on anxiety and its physical manifestations.

Introduced diaphragmatic breathing exercises to manage acute anxiety symptoms.

Discussed cognitive restructuring techniques to challenge negative thought patterns.

Provided a handout on mindfulness practices and recommended daily practice.

Evaluation (E)

Marcus was engaged and receptive, practicing breathing exercises during the session and reporting feeling “slightly more relaxed.” He expressed willingness to try mindfulness exercises at home. Noted slight improvement in self-reported anxiety levels during the session. Next steps include monitoring symptom frequency and practicing assigned techniques. Follow-up scheduled for 07/02/2025 at 10:00 AM via telehealth.

Additional Notes

Marcus identified strong family support as a resource.

No safety concerns reported; client denied suicidal ideation or intent.

Discussed confidentiality and telehealth consent; Marcus verbalized understanding.

Signature: Rachel Carter, LCSW

Date Signed: 06/18/2025

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