Psychology · Templates

Therapy progress note template

Emphasizes treatment goals, interventions, and patient response—the workflow therapists need—rather than medication and diagnostic complexity.

Template content

Copy or download, then paste into Wavo under My Templates.

Therapy Progress Note

Session Information
- Modality, attendees, and session focus.

Subjective / Patient Report
- Symptoms, stressors, functioning, and progress toward treatment goals in the patient's words when useful.

Interventions
- Techniques used (e.g., CBT restructuring, exposure, DBT skills, motivational interviewing) and themes explored.

Patient Response
- Engagement, insight, skill practice, and emotional response in session.

Risk
- Suicidal ideation / safety assessment if indicated this visit.

Assessment / Progress Toward Goals
- Status relative to treatment goals and any goal updates.

Plan
- Homework, next-session agenda, referrals/coordination, and follow-up.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Separates therapy workflow from psychiatric medication documentation.
  • Keeps goals and interventions visible across longitudinal care.
  • Compatible with custom clinic language and modalities.
  • 1Psychologists and therapists
  • 2Ongoing outpatient psychotherapy
  • 3Teletherapy progress documentation

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Session Information
Individual psychotherapy, in-person, 50 minutes. Focus: social anxiety around team meetings.

Subjective
Client reports attending 2 of 3 standups this week; anticipatory anxiety 7/10 before speaking. PHQ-9 = 8; GAD-7 = 11. Sleep adequate. No new medications.

Interventions
Reviewed cognitive model of social anxiety; practiced brief cognitive reframe and 4-7-8 breathing. Planned graded exposure: one verbal contribution in next standup.

Patient Response
Engaged, initially skeptical of breathing then noted decreased chest tightness. Committed to exposure step with anticipated SUDS 6/10.

Risk
Denies SI/HI/self-harm. Risk low.

Assessment / Progress
Goal 2 (reduce meeting avoidance) partially met—attendance improving; verbal participation still limited. Therapeutic alliance strong.

Plan
Complete one verbal contribution; log SUDS. Next session: review exposure and introduce interoceptive basics. Follow-up in 1 week.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.