Therapist Notes Template

A simplified therapist note template is guaranteed to help therapists promptly produce comprehensive, detailed, and accurate documents.

By Audrey Liz Perez on Jul 05, 2024.

tick

Fact Checked by Ericka Pingol.

Use Template
Therapist Notes Template PDF Example
ToolbarShare uiAI Icon

How to Use This Template For Therapist Notes

Any type of therapist note example, template, or general resource that you are using should ideally be saving you time and simplifying your workload. In the development of our therapist note template, we took into consideration the busy lives that therapists often lead, and tried to create a solution that would streamline the documentation process. This is why utilizing our therapist note template only requires 3 simple steps:

Step One: Access the PDF

We’ve included a link to the therapist note template on this page, so all you have to do is click on it and it will take you to the document. From here, you can save the template onto your device or edit it straight away.

Step Two: Fill out the template

After you have accessed the template, it’s time to fill it out. Obviously, this step comes after you have had a session with a client, but it’s a good idea to have the document ready to go immediately after your sessions. This way, you’ll be able to quickly and accurately fill out the therapist's note, without missing any crucial details.

Step Three: Save the document securely

Finally, it’s time to save the therapist note securely. Although in the future you may wish to share the contents of the therapist note with authorized members, for example, the patient themselves, you still need to keep the note secured. There are a couple of different options when it comes to storage. You can keep your documents physically secured, or you can save them in an online location (using an EHR). While both of these employ safeguards that will help protect patient privacy, using an online platform is likely the safest (and easiest) option.

Therapist Notes Example (Sample)

To help you visualize what the therapist note template will look like in action, we’ve created a sample document. The specific information that is included in this will differ depending on the type of session you have with a client, but it should give you a bit of an insight into what a finished note will look like. 

Here is our copy of a sample therapist note template: 

Therapist Notes Example (Sample)

Who Can Use this Printable Therapist Note Template?

Within the healthcare industry, therapy is a broad field. There is a range of different kinds of therapists who may all have different treatment and patient specializations. We understand this diversity and attempted to create a note template that would be applicable to as many therapists as possible. Some of the therapists who can use our printable therapist notes include:

  • Mental Health Therapist
  • Marriage and Family Therapist
  • Addiction Therapist
  • Behavioral Therapist
  • Divorce Therapist
  • Child Therapist
  • Cognitive-Behavioral Therapist
  • Trauma Therapist
  • Clinical Therapist 

Our PDF template can easily be utilized in sessions involving all of the above types of therapy. It can also be used for individual or group therapy sessions with patients of all ages: children, teenagers, and/or adults.

Why is This Template Useful For Therapists?

Our note template has a range of uses for therapists looking to streamline their documentation process, including the following:

  • Saves time: Arguably the most influential use of our therapist note template is how much time it will save. You will be able to easily access and edit our note template without having to worry about creating a format or structure. Writing notes can be a time-consuming process, but with our template, this process is guaranteed to be both easier and faster. 
  • Organization: Maintaining the organization of your documentation is a very important but often overlooked aspect of working as a therapist. Utilizing templates that have predetermined structures can help to elevate your organization. Additionally, filling out our template online makes it easier to save to your EHR, which in turn simplifies accessibility. 
  • Efficiency: Using our template to save time and increase organization will lead to improved efficiency. Streamlining the workflow within your therapist practice is important, but often difficult to achieve. With our therapist note template, you will be able to speed up the process of writing documentation without compromising the quality of the finished results.
Therapist software feedback

Benefits of Therapist Notes 

Using a therapist note template in your healthcare practice will incur a wide range of different advantages. The systemization of these templates is guaranteed to optimize productivity and lead to the production of better documents. Some of the benefits associated with using our therapist note template include:

Track the progress of your patients 

Importantly, the primary aim of most documentation is to assess the efficacy of treatment plans. With our therapist note template, you will be able to easily assess how your patient is progressing. You can compare recent notes with older notes to visualize the trajectory of your patient’s treatment and determine whether changes need to be made to their care plan. 

Improve accuracy 

Therapist notes are pointless if they aren’t accurate. And while we are certain most therapists try their hardest to write accurate notes, stress and lack of time can lead to mistakes. With our therapist note template, the number of errors and missing information will be reduced. Writing your notes into a template helps with structure and ensures consistency, which increases the overall accuracy and effectiveness of your documents. 

Better clinical outcomes 

Producing accurate therapist notes that are efficiently shared between care providers will lead to better overall clinical outcomes. Improved communication ensures that every relevant care provider has all of the knowledge required to make informed clinical decisions. 

Consolidate knowledge 

As a therapist who treats a number of patients simultaneously, it can be hard to constantly remember every detail of each of these clients. Writing effective therapy notes will allow you to quickly review your patients and reassess their individual cases. 

Workflow 

With our therapy note template, you will be able to save time writing your documentation, which in turn will elevate your workflow. Having instant access to a ready-to-go template will reduce the amount of time you spend writing, helping to boost productivity.

Why Use Carepatron For Therapist Notes?

Carepatron is an all-in-one healthcare software that can help streamline the administrative and clinical processes at your practice. In addition to offering extensive templates, Carepatron is integrated with voice-to-text transcription software that allows therapists to speak into their device, and the platform will produce the typed document. Once you have completed your therapy notes, Carepatron can store them securely on their platform, protected by both physical and electronic safeguards. As technology continues to be introduced into the healthcare industry, finding options that suit your business needs has never been easier. Carepatron is a fantastic option for therapists that are looking to streamline their clinical documentation process, while simultaneously elevating the quality of the produced documents - it’s a win-win!

Therapist Note Software
What should be included in a therapy note?
What should be included in a therapy note?

Commonly asked questions

What should be included in a therapy note?

The exact information that you include in your therapist note will depend on the type of session that you have with your client. When you are writing your notes, you may choose to use a specific structure (e.g. SOAP, DAP, or BIRP). However, writing them without a predetermined format is just as acceptable. Under HIPAA guidelines, the type of information that you include in a therapy note differs from that of a progress note. It includes details concerning a conversation you have had with a patient (and this could be a session, a phone call, or another type of encounter). It’s important that you don’t include information regarding diagnosis, symptoms, clinical test results, and treatment plans - otherwise the document will be considered a progress note.

Can my patient read my therapist notes?

Therapy notes are not legal documents, which means that therapists are not required to grant viewing access to their patients. However, patients are allowed to request access, and therapists can decide whether to approve this or not.

How do you write notes as a therapist?

The timeliness of writing therapy notes is important. You don’t want to be writing too much during the session with the patient, otherwise, it may seem as though you are distracted. On the other hand, if you wait too long you may forget important details. The best option is to write your therapy notes immediately after each session with a patient.

Join 10,000+ teams using Carepatron to be more productive

One app for all your healthcare work