Psychotherapy Note Template
A simple, free psychotherapy note template designed to improve organization and help optimize the documentation workflow at your therapy practice.
Fact Checked by Ericka Pingol.
What is a Psychotherapy Note Template?
A psychotherapy note refers to a therapist’s private notes regarding a session or general encounter with a patient. Psychotherapy notes differ from progress notes in their status as non-legal, optional documents that are not made to be shared. In turn, a progress note is a legal, required document that is frequently shared between all members of a patient’s care team, insurance providers, and even lawyers. In order for psychotherapy notes to be properly differentiated from progress notes, there are a few things that they aren’t supposed to contain: diagnosis, symptoms, clinical test results, and treatment plans. If your document has any of this information, it will be legally considered a progress note.
So what exactly do psychotherapy notes contain? This is evidently fairly dependent on the encounter that you have with a patient, but the general purpose of a psychotherapy note is to consolidate your own knowledge and memory regarding a specific patient. You may want to record an observation, hypothesis, or generalized notes to help provide context to your treatment and ensure you remember all important details of the patient’s health condition. To help healthcare practitioners write efficient and effective psychotherapy notes, we’ve created a PDF template that can be downloaded and utilized for free.
Free Psychotherapy Note Template
Check out these daily psychotherapy note templates to improve your clinical documentation, workflow, and therapy outcomes.
How to Use This Template for Psychotherapy Note
We know how busy the schedule of a therapist can get, particularly if they typically treat numerous patients. To help ease the work requirements of clinicians, we’ve ensured our psychotherapy note example template is very easy to use, you just need to adhere to the following steps:
Step One: Save the PDF
There is a link to the psychotherapy note template on this page. All you have to do is click on the link and you’ll be taken directly to a PDF version of the document. From here, you can save the PDF onto your computer where it can be printed off or edited electronically, depending on your preference.
Step Two: Make the necessary edits
After you have had an encounter or a session with a patient and you want to write a psychotherapy note, it’s time to edit the document. You can do this electronically (which we recommend) or physically, by printing off a hard copy and handwriting your notes. When the template is ready, simply add the relevant changes.
Step Three: Save and/or store the document securely
Although psychotherapy notes are not technically legal documents, meaning they aren’t designed to be shared among providers, they still need to be stored in a secure way. The method you use to store your psychotherapy notes will depend on whether you’ve written them electronically or physically. Either of these options is fine, as long as you have adequate safeguards in place. The information contained in psychotherapy notes is confidential, so you need to ensure that your patient's privacy is protected at all times.
Psychotherapy Note Example (Sample)
We know that sometimes the best way to learn how to use a new resource is to see it in action, which is why we’ve created a sample psychotherapy note. This example should give you insight into the type of information that should be included in a psychotherapy note, and how it can be structured using our note template.
Download this Psychotherapy Note example here:
Who Can Use this Printable Psychotherapy Note Template?
We have created our psychotherapy progress note with a wide range of different therapists in mind to ensure it is as applicable as possible. Some of the types of therapists that will benefit from using our psychotherapy note template include:
- Counselors
- Mental Health Counselors
- Psychologists
- Psychiatrists
- Psychotherapists
- Clinical Social Worker
It is likely that each of these types of clinicians will have their own specializations and techniques when it comes to treating patients. We’ve ensured that the structure and general format of our psychotherapy notes are applicable to all clinicians, regardless of these specific specializations. Further, you will be able to reap the benefits of this template irrespective of how long you’ve been working as a therapist. Trainee therapists who are just learning how to write clinical documentation will find the template extremely useful, as it helps structure information and ensures they are including relevant details. On the other hand, seasoned professionals who have been working as a therapist for years will also benefit from using the template, as they can sharpen up the conciseness of their documents and focus on efficiency and accuracy.
Why is This Template Useful for Psychotherapist?
If you save our psychotherapy note template and implement it into your practice, you will likely find that it has a range of different uses in the day-to-day workflow of your business. These uses include:
- Standardization: Using our psychotherapy note template will guarantee standardization across your clinical documentation. While the specific contents of each psychotherapy note will obviously differ, by using the same format and structure, you can introduce some standardization into your documentation, which will improve readability.
- Saves Time: The amount of time that you will save by using a psychotherapy note template is definitely one of its most useful aspects. You no longer have to structure your own documents or create a brand new page every time you want to write a psychotherapy note, as all of this work has been done for you. Instead, you simply need to access the PDF template we’ve created and edit directly onto the document.
- Efficiency: Every therapy practice is looking for ways they can improve efficiency at their workplace, and our psychotherapy note template is one of the best ways that this can be achieved. As we described, using our template will save you a significant amount of time, which can instead be spent completing more pressing tasks and improving the general productivity at your clinic.
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Why Use Carepatron For Psychotherapy Note?
In order to optimize clinical and administrative processes at your therapist practice, we greatly recommend utilizing practice management software like Carepatron. Carepatron is an all-in-one solution that has been developed in collaboration with therapists, ensuring that it authentically meets the needs of healthcare practitioners. Carepatron offers its users access to a robust set of templates, including this psychotherapy note. Additionally, Carepatron has voice-to-text transcription that allows users to speak into their device, which will translate the text for you, saving you countless hours. When you have completed writing your documents, the platform can store them for you on its online servers. Carepatron takes compliance seriously, and their storage capabilities have high-quality electronic and physical safeguards, helping to ensure the privacy of your patients is protected at all times.
If you are looking for a system that offers a wide range of different solutions then you’ve come to the right place. In addition to integrating with documentation features and an EHR, Carepatron has tools that target medical billing, coding, scheduling, mobile health, telehealth, and patient engagement – and all for free!
Commonly asked questions
A psychotherapy note is different from a progress note, and the formatting isn’t as strict. Because psychotherapy notes focus on private details and points of interest from the perspective of the therapist, they do not need to follow a specific format.
The length of your psychotherapy note will depend on the type of information that you are recording, but a good rule of thumb is around 1-2 pages. Psychotherapy notes can be as comprehensive or as brief as you like, considering they aren’t made to be shared with anyone else.
In order to be considered psychotherapy notes (and not progress notes), these documents are not allowed to contain certain kinds of information:
- Summary of treatment or intervention
- Test results
- Medication details or records
- Diagnosis
