Case Notes Template

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Video & audio overview of the template

What is the theory behind the template?

There can be confusion between a progress note and a process note/ case note. A progress note requires certain information and must be included in the client file. If the client requests their file they will be able to read these progress notes. 

A process/ case note is for the therapist and is not for the client. These case notes are where thoughts, hypotheses, further research, etc. are noted. These are the notes you might take to supervision.

How will the template help?

This template offers a basic guideline on what could be included in a process/ case note. The template offers an opportunity to continue your case conceptualization throughout the intervention.

How to use the template?

Although a process/ case note does not need to be completed for every session it is important to regularly complete the process notes because without them you may battle to fully engage with the client and the therapeutic process.

Remember that this is a template and a guideline, you may wish to tailor it to your specific practice or the legalities required in your location.

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References

1.-

Lees, R., Sveen, J., Stevens, M., McNally, M. (2015) Progress Notes vs Process Notes. https://www.robertalees.com/wp-content/uploads/sites/6205/2015/05/Process-vs-Progress-Notes.pdf