Mental health progress notes document client sessions in behavioral health, psychiatric, and therapy settings. A well-structured template helps clinicians capture mood, interventions, risk factors, and treatment progress consistently.
This guide provides a mental health progress note template, example, and best practices for therapists and behavioral health professionals. Part of our therapy notes templates collection.
These templates help therapists document sessions, track client progress, and maintain structured clinical documentation while reducing administrative burden.
This template is designed for behavioral health and mental health documentation. Replace bracketed text with session-specific content.
Client Name: Date of Session: Session Type: (In-Person / Telehealth) Duration: Mood and Affect: [Client's reported mood and observed affect.] Presenting Concerns: [Primary concerns discussed during the session.] Behavioral Observations: [Observable behaviors, engagement level, and presentation.] Risk Assessment: [Safety screening, suicidal ideation, self-harm — if applicable.] Interventions Used: [Therapeutic techniques and approaches applied.] Client Response: [How the client responded to interventions.] Progress Toward Treatment Goals: [Evaluation of progress since last session.] Treatment Plan Updates: [Any changes to the treatment plan or goals.] Plan for Next Session: [Next steps, homework, and follow-up schedule.]
Client Name: Date: Session Type: Duration: Mood and Affect: Presenting Concerns: Behavioral Observations: Risk Assessment: Interventions Used: Client Response: Progress Toward Treatment Goals: Treatment Plan Updates: Plan for Next Session:
Client: M.T.
Date: March 22, 2026
Session Type: In-Person
Duration: 50 minutes
Mood and Affect
Client reported mood as "anxious." Affect was congruent with reported mood — restless, fidgeting, and increased speech rate noted.
Presenting Concerns
Client described escalating worry about health, including frequent checking behaviors and difficulty tolerating uncertainty about physical symptoms.
Behavioral Observations
Client was cooperative and engaged. Eye contact was appropriate. Speech was pressured at times. No psychomotor retardation observed.
Risk Assessment
No suicidal ideation, homicidal ideation, or self-harm behaviors reported or observed. Client denies access to means. Safety plan not indicated at this time.
Interventions Used
CBT-based psychoeducation about health anxiety cycle. Introduced uncertainty tolerance exercises. Reviewed behavioral experiment design for testing health-related assumptions.
Client Response
Client demonstrated understanding of the anxiety maintenance cycle. Expressed willingness to attempt behavioral experiments between sessions. Some resistance to reducing checking behaviors noted.
Progress Toward Treatment Goals
Moderate progress. Client shows increased insight into anxiety patterns. Behavioral change remains early-stage. Checking behaviors have not yet decreased.
Plan for Next Session
Review behavioral experiment outcomes. Continue exposure-based work targeting uncertainty tolerance. Monitor checking behavior frequency. Next session in one week.
See more examples in our mental health progress note example.
Mood and affect observations
Presenting concerns and session themes
Behavioral observations and engagement level
Risk assessment when clinically indicated
Interventions and therapeutic techniques used
Client response to treatment
Progress toward established treatment goals
Treatment plan updates and next steps
Behavioral health sessions
Psychiatric follow-up appointments
Community mental health documentation
Substance use treatment sessions
Individual therapy in mental health settings
Telehealth mental health sessions
Document mood and affect consistently
Include risk assessment when clinically indicated
Keep notes concise and clinically relevant
Connect interventions to treatment goals
Write notes promptly after sessions
Maintain consistent formatting across sessions
For more strategies, see our documentation best practices guide.
Structured templates help behavioral health professionals:
Reduce documentation time while maintaining thoroughness
Ensure consistent risk assessment documentation
Track mood, affect, and behavioral changes over time
Maintain compliance with behavioral health standards
Improve treatment planning with structured progress data
Mental health professionals use several documentation formats depending on their setting and requirements:
Therapists in behavioral health settings
Community mental health clinicians
Psychiatrists and psychiatric nurse practitioners
Substance use treatment counselors
Psychologists
Social workers in clinical settings
AI-assisted documentation can generate structured mental health progress notes in seconds from brief session summaries.
No credit card required.
A mental health progress note documents what occurred during a therapy or behavioral health session. It typically includes presenting concerns, clinical observations, interventions, client response, and treatment planning. These notes are part of the official clinical record.
Mental health progress notes should include mood and affect observations, presenting concerns, interventions used, client response, risk assessment (if applicable), progress toward treatment goals, and a plan for next steps.
Progress notes should be completed for every clinical session. Writing notes promptly after sessions improves accuracy and reduces documentation backlog.
Generate structured progress notes in minutes — no session recording required.