Complete therapy documentation covers every stage of treatment — from intake through discharge. This guide links to templates for each documentation type therapists need.
Part of our therapy notes templates collection.
Document initial client information, history, and treatment planning.
Key sections:
Client Information
Presenting Concerns
Mental Health History
Medical History
Risk Assessment
Treatment Goals
Initial Assessment
View Intake Template
Document individual therapy sessions with structured clinical notes.
Key sections:
Presenting Concerns
Session Summary
Interventions Used
Client Response
Progress Toward Goals
Plan
View Session Template
Track treatment progress across sessions.
Key sections:
Current Symptoms
Interventions
Client Response
Progress
Treatment Plan Updates
View Progress Template
Document treatment conclusion and recommendations.
Key sections:
Treatment Summary
Progress Toward Goals
Final Assessment
Recommendations
Follow-Up Plan
View Discharge Template
Complete therapy documentation follows a structured workflow from the first contact through discharge:
Intake Documentation
Capture client history, presenting concerns, and initial assessment during the first session.
Treatment Planning
Define measurable goals, objectives, and planned interventions based on the intake assessment.
Session Documentation
Document each therapy session including interventions, client response, and progress.
Progress Reviews
Periodically review and update treatment plans based on client progress.
Discharge Documentation
Summarize treatment outcomes, provide recommendations, and document the conclusion of care.
Complete documentation promptly after each session
Use consistent templates and formats
Document interventions specifically
Track progress with measurable outcomes
Maintain organized records throughout treatment
Follow your organization's documentation policies
No credit card required.
Therapists typically need intake notes, session/progress notes, treatment plans, and discharge or termination notes. The specific requirements depend on the practice setting, licensing board, and insurance requirements.
The most common formats are SOAP, DAP, and BIRP notes. Many therapists also use general progress note formats. The best choice depends on your setting and documentation preferences.
Documentation should be completed after every clinical contact — including intake, individual sessions, group sessions, and discharge. Writing promptly improves accuracy.
Yes. Most licensing boards, employers, and insurance payers require clinical documentation. Proper documentation supports continuity of care, compliance, and legal protection.
Generate structured therapy notes in minutes — no session recording required.