CLIENT PROGRESS NOTES Client Name: ID#: Behavior: What are the Clt’s Intervention: What Clt Response: What was the Plan: Does the tx plan observations, thoughts and & objectives were Clt’s response to the session need to be updated? What comments? What are the discussed? Was homework and their progress in are the Counselor’s next End (s) Note of # Counselor’s observations reviewed or assigned? reaching treatment goals? steps and when is the next Plan (affect, mood, appearance)? session date? Date Date Type Time Tx Service Service Start/ Signed Services Counselor or Therapist is required to legibly print their name, sign and date EACH note. Intake/Individual-I Group=G Crises=C Collateral=CO Case Mngt=CM Tx Plan=TP Transport=TR Medication=M Discharge Plan=DP Index #s: 1) Substance Use Disorder 2) Mental Health 3) Physical Health 4)Employment/Education 5) Financial/Housing 6) Legal 7) Psycho-Social /Family 8) Spirituality To Be Added=TBA Not Applicable=N/A The date of the counseling session may be different than the date note is signed. Notes must be legibly printed, signed and dated by the counselor/therapist the day of service or no later than 7 calendar days from the date of the counseling session.
CLIENT PROGRESS NOTES Client Name: ID#: Service Date Type of Service Start/ End Time Tx Plan # (s) Behavior: What are the Clt’s observations, thoughts and comments? What are the Counselor’s observations (affect, mood, appearance)? Intervention: What Clt & objectives were discussed? Was homework reviewed or assigned? Response: What was the Clt’s response to the session and their progress in reaching treatment goals? Plan: Does the tx plan need to be updated? What are the Counselor’s next steps and when is the next session date? Date Note Signed Services Counselor or Therapist is required to legibly print their name, sign and date EACH note. Intake/Individual-I Group=G Crises=C Collateral=CO Case Mngt=CM Tx Plan=TP Transport=TR Medication=M Discharge Plan=DP Index #s: 1) Substance Use Disorder 2) Mental Health 3) Physical Health 4)Employment/Education 5) Financial/Housing 6) Legal 7) Psycho-Social /Family 8) Spirituality To Be Added=TBA Not Applicable=N/A The date of the counseling session may be different than the date note is signed. Notes must be legibly printed, signed and dated by the counselor/therapist the day of service or no later than 7 calendar days from the date of the counseling session.
Client_Progress_Note.docx