Progress notes are used by counsellors to track sessions with clients. If you're working with a new client, you'll complete an intake interview, and develop a treatment plan. Once you have the treatment plan in place, you'll begin to work on goals during your weekly or biweekly counselling sessions. Many counsellors use progress notes and written summaries to document the quality and effectiveness of the treatment process. You may find that you use the notes in the long term to assess possible patterns, problem behaviours or improvements in client health.
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Use at least one page per session to summarise your notes. You may choose to use photocopied forms and write your notes by hand, or you can create a computerised template and type your notes after the session. Your forms should always include the client's name, diagnosis, treatment plan, and pertinent information at the top.
Note specifics, such as client concerns or your observations and interpretations about the client. It's important to track the client's mood, demeanour and even personal appearance. If she's anxious or depressed, for example, she may have a hard time concentrating or explaining her ideas, and she may appear dishevelled or even fatigued. As you note these observations, over time you'll likely see possible patterns and even improvements.
Prepare a summary of the counselling sessions by rereading each of the individual session's notes. Review the progress and note specific treatment goals that have been reached. For example, if a goal was to use regular exercise as a treatment for depression, you can asses the extent to which the client has reached this goal. You'll need to summarise the client's initial reason for seeking therapy and the length of time she attended counselling. You can then summarise how the client communicated and determine whether the counselling process resulted in an noteworthy changes.
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