Psychotherapy Progress Note (DAP, Child/Adolescent)

Date of Service: [date]

Client: [name, DOB/age]

Session Time: [start time – end time, total psychotherapy minutes]

Modality/Location: [in-person clinic/school/home / telehealth video/audio with client's physical location]

Participants: [youth present Y/N; caregiver(s) with relationship and portion of session; other participants with authorization status]

Treatment Plan Goals Addressed: [goal number(s) or brief identifier]

Data

[One-sentence presenting focus or reason for today's visit]

[Brief narrative integrating youth report and caregiver report as applicable] (For younger children, ground statements in observable behavior and play rather than abstract insight. Use confidentiality-aware wording appropriate for records accessible to caregivers.)

Objective observations: [clinician-observed affect, engagement, activity level, impulse control, and notable behaviors appropriate to developmental level] (For play-based sessions, describe observable play themes and behaviors before any interpretation.)

Interventions provided: [specific techniques used and how delivered] (Name concrete techniques, not just therapy labels.)

Youth response/participation: [engagement level, skill practice participation, meaningful shifts during session]

Risk/safety screening: [screening completed Y/N; findings; protective factors] (If not assessed, briefly state why and note any mitigation provided.)

Assessment

[Clinical impression of current symptom severity and functional status at home, school, and with peers] (Frame developmentally.)

Goal-based progress: [for each goal addressed: goal identifier, metric/evidence used, progress trend as improving/stable/worsening with brief basis] (Required for medical necessity documentation.)

Overall risk level: [low / moderate / high / not assessed] (If assessed, include brief clinical reasoning and protective factors; if elevated, note whether higher level of care was considered.)

[1–2 sentences supporting continued need for psychotherapy, tied to functional impairment and treatment goals]

Plan

Next session focus: [planned focus and therapeutic approach for next visit]

Between-session tasks: [youth and/or caregiver tasks with specificity about what, how often, and how tracked] (Include only if assigned.)

Coordination of care: [planned contacts with school, prescriber, or other providers; authorization status] (Include only if planned or conducted.)

Safety plan: [reviewed/updated Y/N; key elements] (Include only if risk was identified or safety plan was addressed.)

Next appointment: [date/time, modality] (If not scheduled, note plan to schedule.)

Clinician Signature/Credentials: [signature with credentials; supervisor co-signature if applicable]