Progress Note for Client #
Date:
Time:
Present:
Adult Male
Billing Code:
:
am/
Adult Female
90791 (eval)
pm
Session Length:
Child Male
Child Female
90834 (45 min. therapy)
45 min.
90847 (family)
Progress
Select
Select
Select
In-Session Interventions and Assigned Homework
Client Response/Feedback
Plan
Continue with treatment plan: plan for next session:
Modify plan:
Next session: Date:
Crisis Issues:
Time:
:
am/
No indication of crisis/client denies
pm
Crisis assessed/addressed: describe below
________________________________, _________________
Clinician’s Signature,
License/Intern Status
Case Consultation/Supervision
Notes:
________
Date
Not Applicable
Collateral Contact
Not Applicable
Name:
Date of Contact:
Time:
Written release on file:
Sent/ Received
Notes:
:
am/
In court docs
pm
Other:
________________________________, _________________
Clinician’s Signature,
License/Intern Status
________
Date
________________________________, _________________
Supervisor’s Signature,
License
________
Date
Other:
minutes
Other:
90837 (60 min. therapy)
Symptom(s)
Duration and Frequency Since Last Visit
1:
2:
3:
Explanatory Notes on Symptoms:
60 min.
1
© 2013. Diane R. Gehart, Ph.D. All rights reserved. www.mftcompetencies.org
Other: