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Here is an example of a person-centred progress note: ?Today John spent the morning preparing for his upcoming job interview. He became quite anxious and refused to eat breakfast. I was able to offer emotional support and we worked on some breathing exercises to help him calm down.
For counselors, progress notes often take a journal-like form, focusing on the process between therapist and client and the counselor's own thoughts and feelings in the work. Many counselors often choose to use a SOAP (subjective, objective, assessment, plan) format as it allows for a consistent structure.
Intake notes are a type of note used specifically in psychotherapy settings and mental health. They include detailed information about the mental health history of the client, current symptoms and concerns, as well as personal and social history, family history, and any previous treatment received.
These separate "process notes" are what we are calling "psychotherapy notes." Summary information, such as the current state of the patient, symptoms, summary of the theme of the psychotherapy session, diagnoses, medications prescribed, side effects, and any other information necessary for treatment or payment, is ...