Some therapists keep long process notes and others are brief and minimal. This template allows space for both, while providing a structure that will serve us in both remembering important information and considering our supervision needs.
The form is based on SOAP note structure with the following sections:
- Themes
- Medical
- Subjective
- Objective
- Assessment
- Plan
- Interventions
- Concerns
- Resources
- To Do
Further questions are included and the template can be edited for use as a treatment plan, progress report or clinical session note.
BONUS WORDS FOR WRITER’S BLOCK
I have also collected 125 useful descriptive words from my notes and added them in a table in case you get stuck and need some inspiration!