Psychology Session Notes Template

Description:

This template provides a structured framework for therapists to document ongoing psychology or therapy sessions, capturing key details about the client’s presentation, interventions, progress, and next steps. It is designed for general use across sessions, offering flexibility for various therapeutic approaches while ensuring comprehensive notes that support clinical continuity and professional standards.

Note:

This template is intended for regular therapy sessions following an initial intake. Adjust sections as needed based on the session’s focus, client needs, or therapeutic modality.

Date: [Record the date of the therapy session for accurate tracking and reference in the client’s treatment timeline]

Client Name: [Enter the client’s full legal name to ensure proper identification within the session notes]

Therapist Name: [Enter the therapist’s full name to establish accountability and ownership of the documentation]

Session Number: [Note the session number in the sequence of therapy to track progress over time and contextualize the client’s journey]

Session Overview

[Provide a brief summary of the session’s purpose and focus, including the primary topics discussed or goals addressed, to give a snapshot of what transpired and set the stage for detailed notes below.]

Client Presentation

Mood and Affect: [Describe the client’s emotional state and observable affect during the session, such as anxious, flat, or upbeat, including any changes observed, to assess their current psychological condition.]
Behavior and Engagement: [Note the client’s behavior, level of participation, and non-verbal cues, such as eye contact, fidgeting, or attentiveness, to document how they interacted with the therapeutic process.]
Reported Symptoms: [Record the client’s self-reported symptoms or concerns raised during the session, including intensity, frequency, or changes since the last meeting, to track their subjective experience.]

Therapeutic Interventions

[Detail the specific techniques, strategies, or approaches used during the session, such as cognitive restructuring, mindfulness exercises, or reflective listening, including the rationale and duration if relevant, to document the therapeutic actions taken and their intended purpose.]

Client Response

[Describe how the client reacted to the interventions emotionally, verbally, or behaviorally, such as showing insight, resistance, or relief, to evaluate the effectiveness of the session’s approach and the client’s engagement with it.]

Progress and Observations

Progress Toward Goals: [Assess the client’s movement toward their established therapy goals, noting specific improvements, setbacks, or stagnation, to measure the trajectory of treatment and adjust plans as needed.]
Therapist Observations: [Record the therapist’s clinical impressions, insights, or notable patterns observed, such as recurring themes or new revelations, to inform future sessions and deepen understanding of the client’s needs.]

Risk Assessment

[Document any indications of risk, such as suicidal thoughts, self-harm urges, or threats to others, including severity, intent, and protective factors, to ensure safety is monitored and addressed promptly within the therapeutic context.]

Homework or Tasks Assigned

[List any assignments, exercises, or reflections given to the client to complete before the next session, including their purpose—like practicing coping skills or journaling—to reinforce therapy goals and encourage active participation outside sessions.]

Plan for the Next Session

[Outline the intended focus or activities for the upcoming session, such as exploring a specific issue, introducing a new technique, or reviewing homework, to provide direction and continuity in the therapeutic process.]

Additional Notes

[Include any miscellaneous information not covered above, such as logistical details (e.g., rescheduling), client questions, or external factors affecting the session, to ensure all relevant context is captured.]