Adolescent Psychology Progress Notes: Four Worked Examples

See how progress notes change across therapy

A progress note written during intake should not look the same as a note written during intervention or at the planned ending of therapy.

This resource follows one fictional 15-year-old client across four psychology sessions. It demonstrates how documentation can develop as more information becomes available, the working formulation becomes clearer and therapy progresses.

What is included

Intake Session 1: Presenting concerns and current context

Covers consent and adolescent assent, confidentiality, the perspectives of the young person and caregiver, current functioning, initial goals and safety.

Intake Session 2: Developmental interview

Covers pregnancy and birth history where known, developmental milestones, health, sleep, education, learning, sensory experiences, social and emotional history, family patterns and optional genogram use.

Intervention Session 4: Practising change

Demonstrates progress monitoring, school participation, sensory adjustments, behavioural practice, clinical reasoning, setbacks and risk clarification.

Review and Ending Session 10: Outcomes and maintenance

Demonstrates outcome review, ongoing adjustments, early warning signs, maintenance planning, information sharing and planned ending.

A consistent progress-note structure

Each example uses the same practical headings:

• Time / place / who was there
• Agenda / theme
• Review
• Observations
• Plan / goals
• Risk

Using the same structure across all four examples makes it easier to see how the content and level of detail change throughout therapy.

The developmental interview includes

• Pregnancy and birth history where relevant and available
• Early developmental milestones
• Medical, hearing, vision and sleep history
• Education and learning
• Social communication and relationships
• Sensory experiences
• Emotional and mental health history
• Family structure and relevant family history
• Optional three-generation genogram documentation
• Strengths, interests and protective factors
• The source and limitations of collateral information

The example also demonstrates that developmental information should contribute to a broader formulation rather than being treated as proof of a diagnosis on its own.

What the examples demonstrate

• Recording consent, assent and confidentiality discussions
• Including both adolescent and caregiver perspectives
• Separating reported information from clinical observations
• Documenting collateral information and its limitations
• Avoiding premature diagnostic conclusions
• Connecting interventions to the working formulation
• Distinguishing helpful adjustments from avoidance
• Recording measurable progress without overstating change
• Documenting setbacks without treating them as treatment failure
• Clarifying ambiguous language during risk assessment
• Writing specific and individualised risk documentation
• Documenting maintenance planning and a planned ending

Who is this resource for?

This resource may be useful for:

• Psychologists
• Provisional psychologists
• Psychology interns and trainees
• Clinical supervisors
• School psychologists
• Allied health clinicians
• Private practices developing documentation guidance
• Students learning how progress notes change across therapy

Format

• Four-page A4 printable PDF
• One complete worked example per page
• One consistent fictional adolescent case
• Suitable for printing or digital viewing
• Minimal-ink professional design
• Australian spelling and professional context
• No real client information

This resource provides fictional educational examples only. It is not legal advice, a mandatory documentation standard or a substitute for clinical judgement, supervision, workplace policies and applicable professional requirements. Practitioners should adapt their documentation to the person, referral question, setting, consent arrangements, risk presentation and purpose of the record.