Therapy progress notes can be adapted and amended according to their purpose. Because various forms of therapy cater to specific groups and needs, their differences may be reflected in their therapy notes. As a result, we have compiled some examples of therapy progress notes in the standard SOAP format for you to use as templates for your practice.
Family therapy progress notes
To help, here is a family therapy progress notes example:
Sam has indicated that he feels sad often, stating, “I feel low a lot of the day like I just don’t look forward to anything or have any motivation to do anything.” Sam’s father, Andrew, states that Sam is irritable and somewhat detached. He explained, “He still doesn’t want to be involved in a lot of family activities we have, and he gets easily frustrated over trivial matters.”
Sam has trouble regulating his mood and has anhedonic tendencies with a loss of motivation. He is also somewhat irritable towards his family. Andrew presents an upbeat persona and does not show any signs of depression. He can regulate his mood well, have clear speech, and communicate with clarity.
Sam and Andrew have been attending family therapy for three weeks now. However, it does not seem to be improving, and so this will need to be amended. Sam presents depressive symptoms and does not seem to be making progress. Andrew finds his irritability is becoming more prominent. They will benefit from further treatment.
Sam and Andrew will continue family therapy with me for next week as usual. I will work with Sam in additional sessions to potentially forward him to a psychiatrist for further treatment if his symptoms do not improve within two weeks. We have worked on a family conflict resolution plan of having family meetings on Tuesdays and family movie nights on Friday. Family meetings will give them the chance to air out grievances, communicate, discuss feelings, and hear each other’s side. If no improvements, we will work towards a new treatment plan.
Play therapy progress notes
Play therapy progress notes are also a different form of recreation therapy progress notes, which also benefits from being exemplified here:
Amelia expressed anger towards her classmates without cause, stating, “I don’t know” when asked why she felt that way. When playing with a giraffe toy roughly, by kicking and punching it, Amelia responded with, “I don’t like it.”
Amelia presents behavior management issues in being unable to play with the given toys politely. She presents an irritable mood, as she often screams at the toys and finds difficulty regulating her feelings with a lack of speech and communication.
Amelia has attended one previous session at play therapy and displays the same poor control of her feelings. This is as expected with having only one prior session, so it would benefit Amelia to continue.
Amelia will see me next week as usual, and if within two weeks there is no change in her behavior, we will need to review her treatment plan. I have worked with her to develop a breathing technique in conjunction with others, to modify and help her understand her behavior in the meantime.
Psychotherapy progress note
Provided is a psychotherapy progress notes template, with progress notes for individual therapy. For more information concerning psychiatry note software, many platforms, such as Carepatron, offer additional templates.
Jack is experiencing intense urges to drink and constantly thinks about it, stating, “Most of my day, I think about how much better I’d feel if I just had a few drinks.” He says that despite these feelings, he manages to remain sober. “I think of my kids, which helps a lot with immediate urges, and I know I have to be sober for them.”
Jack has shown up to therapy with sober signs. He has been engaged, present, and alert, and his concentration is improving. He manages to control his urges well so far and abstains. His wife Mandy attested to his behavior, saying he has stayed sober and regulates his mood well.
Considering Jack’s substance abuse experience and how it is a moderate case, it seems fit for him to continue seeing me weekly for therapy. We have worked through controlling and modifying techniques which seem to be working well. Despite his strong urges, he is handling them well.
Jack would benefit from seeing me next week as usual and continuing to review and note his progress. He seems to be making significant improvements, and if he shows signs of relapsing, we will need to create a new treatment plan. Perhaps concerning group therapy.