10+ Psychotherapy Note Examples [ Progress, Soap, Termination ]


To ensure safe practices among health care providers, they should be able to provide something that is designed to record information during counseling. This can be applied to patients with mental health, behavioral and relationship problems. Most of the psychotherapists have to keep notes such as a psychotherapy. They should be able to know about its purpose, content and the legal protections it contains as a document. Look into this article to know more about psychotherapy notes.

10+ Psychotherapy Note Examples

1. Psychotherapy Note Template

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2. Sample Psychotherapy Note

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Size: 36 KB

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3. Authorization to Release Psychotherapy Note

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Size: 1 MB

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4. Psychotherapy Note Example

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5. Psychotherapy Progress Note

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Size: 797 KB

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6. Printable Psychotherapy Note

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Size: 369 KB

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7. Privacy of Psychotherapy Note

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Size: 11 KB

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8. Disclose Psychotherapy Note

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Size: 532 KB

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9. Basic Psychotherapy Note

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Size: 78 KB

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10. Psychotherapy Note Policy

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11. Child Psychotherapy Note

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Size: 71 KB

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What is a Psychotherapy Note?

A psychotherapy note are notes that has the records of health care providers indicating the documents and contents of the conversation made during counseling session. This counseling may refer to a group, joint or family counseling. These records are being separated by other individual records. A psychotherapy note does not  include the list of the medications prescribed by the attending doctor, monitoring, frequencies of a treatment, results of tests, and summary of diagnosis, treatment plan, symptoms, etc.

These type of notes are considered as private documents being kept by a particular therapist. This can not be used publicly. They may contain some of the thoughts and hypothesis coming from a therapist based on what they know about their respective clients. Therapist do not include information about a client’s diagnosis. This notes can only used and taken out during a session with their client.

Difference Between Psychotherapy Note and Progress Note

Based on what you have read earlier, a psychotherapy note is a private document. Unlike progress notes, they can be used in public. In progress notes, you do not need to follow a certain rule of what should be the things you need to write. Some people would choose to be as organized as they want so they use the SOAP format which stands for Subjective, Objective, Assessment and Plan. Progress notes also has the list of the diagnosis, symptoms and any information that is related to the overall status of the client.

HIPAA and Psychotherapy Notes

Health Insurance Portability and Accountability Act (HIPAA) protects psychotherapy notes. Based on what you have known, psychotherapy notes are confidential and cannot be shared by anyone else. You still have to go through the permission of a therapist if you want to look for it. Take note that the protection that has been set for psychotherapy notes include insurance companies. Insurance companies always make sure if it is still worthy to be audited to keep the insurance covered for the mental health services. However, despite the protection that HIPAA gave, it can still be made public under certain circumstances. For example, if it can be used by the court for legal purposes, it can be used in the public.

Considerations

You should always be careful about what you put into the records. Always watch for information that are incriminating. Remember that therapists do not have to worry about having someone else hold the notes. Keep the psychotherapy notes separated from the progress notes. Make sure that whichever is more protective of their client’s privacy should be the one to be followed.

FAQs

Can a patient access their psychotherapy notes?

No. HIPAA does not give the permission to anyone else to access the psychotherapy notes even to the parent.

Do I need written authorization to release my patient’s psychotherapy notes to another provider for treatment purposes?

Yes. You are required to submit an authorization letter for this instance.

If my practice receives a subpoena or court order that states “for all mental health records”, am I also allowed to release it?

Subpoenas do not request for psychotherapy notes. Release only the applicable mental health records except for a psychotherapy note.

In conclusion, a psychotherapy note is really not allowed for public use. Everything that contains within the document should be kept and only the therapist of that assigned client has the right to take out the record for his or her use during a counseling session. The fact that psychotherapy notes have a protection from HIPAA, you should keep your hands off in the record unless you want to face consequences.

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