Copyable telehealth therapy note template
Use this template after a virtual individual therapy session, phone session, or other remote behavioral health visit. It gives you a structured way to document the clinical content of the session while also capturing telehealth-specific details such as modality, client location, privacy, and technical issues.
The template below is written in a practical progress note format. You can adapt it to SOAP, DAP, BIRP, or your practice’s required note structure.
Telehealth Therapy Progress Note Template
Client Name:
Client Date of Birth or ID:
Date of Session:
Start Time:
End Time:
Duration:
Service Type:
Session Format: Video / Phone / Other
Provider Location:
Client Location at Time of Session:
Client Call-Back Number:
Emergency Contact / Local Emergency Resource, if required by practice policy:
Telehealth Check-In:
- Client identity confirmed: Yes / No
- Client consent for telehealth confirmed or on file: Yes / No
- Client privacy confirmed: Yes / No
- Technology issues: None / Describe briefly
Presenting Concern / Session Focus:
Client reported:
Relevant Updates Since Last Session:
Mood, symptoms, stressors, functioning, medication changes if clinically relevant, safety concerns, or major life events:
Mental Status / Clinical Observations:
Appearance:
Behavior:
Mood:
Affect:
Speech:
Thought Process:
Orientation:
Insight / Judgment:
Other observations relevant to telehealth format:
Risk Assessment:
Client denied / endorsed suicidal ideation:
Client denied / endorsed homicidal ideation:
Self-harm concerns:
Protective factors:
Clinical action taken, if any:
Interventions Provided:
Therapist used:
Therapeutic approach or skill practiced:
Psychoeducation provided:
In-session activity, processing, or coaching:
Client Response:
Client engagement:
Client insight or reaction:
Skill use or barriers:
Changes observed during session:
Progress Toward Treatment Goals:
Goal addressed:
Progress observed:
Clinical rationale:
Plan / Next Steps:
Homework or between-session practice:
Focus for next session:
Referrals, coordination, or follow-up needed:
Next appointment:
Provider Signature and Credentials:Completed telehealth therapy note example
This example is fictional and uses a DAP-style structure with added telehealth fields. It is meant to show level of detail, not to prescribe one required format.
Telehealth Therapy Progress Note Example
Client Name: Jordan M.
Client Date of Birth or ID: 04/12/1988
Date of Session: 03/18/2026
Start Time: 2:00 PM
End Time: 2:53 PM
Duration: 53 minutes
Service Type: Individual psychotherapy
Session Format: Secure video
Provider Location: Private office
Client Location at Time of Session: Client's home
Client Call-Back Number: Confirmed on file
Emergency Contact / Local Emergency Resource: Confirmed on file per practice policy
Telehealth Check-In:
Client identity confirmed. Client confirmed they were in a private room and able to participate without interruption. Telehealth consent is on file. No technology issues occurred during the session.
Data:
Client reported increased anxiety over the past week related to an upcoming performance review at work. Client described rumination at night, difficulty falling asleep, and tension in shoulders and jaw. Client stated, "I keep replaying every mistake I made this month." Client denied panic attacks since last session. Client denied suicidal ideation, homicidal ideation, and self-harm urges.
Mental Status / Clinical Observations:
Client appeared on video appropriately dressed and engaged. Speech was clear and normal in rate. Mood was anxious. Affect was congruent with session content. Thought process was logical and goal-directed. Client was oriented to person, place, time, and situation. Insight and judgment appeared fair to good. No psychotic symptoms were reported or observed.
Assessment:
Symptoms remain consistent with anxiety addressed in the current treatment plan. Client demonstrated increased awareness of cognitive distortions, especially catastrophizing and mind reading. Client was able to identify two alternative thoughts with therapist support. Risk level appeared low based on denial of suicidal or homicidal ideation, stated protective factors, future orientation, and engagement in treatment.
Interventions:
Therapist used CBT interventions to help client identify automatic thoughts related to the performance review. Therapist guided client through evidence-for/evidence-against questioning and supported development of a balanced coping statement. Therapist provided psychoeducation on the connection between rumination, sleep disruption, and physiological arousal. Therapist practiced a brief grounding exercise with client during session.
Client Response:
Client was engaged and responsive. Client initially had difficulty identifying evidence against the anxious thought but was able to generate alternative explanations with prompting. Client reported the grounding exercise lowered subjective anxiety from 7/10 to 5/10. Client agreed that writing down balanced thoughts before bed may help reduce rumination.
Plan:
Client will complete one thought record on three evenings before the next session and practice the grounding exercise before sleep. Next session will continue CBT work focused on workplace anxiety and review the thought records. Client scheduled for follow-up telehealth session on 03/25/2026 at 2:00 PM.
Provider Signature and Credentials:
[Provider Name], [Credentials]When to use a telehealth therapy note
A telehealth therapy note is used whenever the clinical service is delivered remotely instead of in the same physical room. That may include a video therapy session, a phone session, a remote intake, a family therapy session by video, or a virtual medication management visit if that is part of your role and documentation workflow.
The clinical note should still document the substance of care: presenting concerns, interventions, client response, progress toward the treatment plan, risk, and next steps. The telehealth portion adds context about how the service occurred and whether anything about the remote format affected the session.
Telehealth details that belong in the note
Telehealth notes do not need to become a long technical report. A few clear fields usually give the record enough context for continuity of care, billing review, supervision, or later clinical review.
- Modality: Document whether the session occurred by video, phone, or another approved format.
- Client location: Record where the client was located during the session, using the level of detail required by your practice.
- Privacy and consent: Note whether the client confirmed privacy and whether telehealth consent was confirmed or already on file.
- Technology issues: Briefly document interruptions, audio problems, disconnections, or no issues if relevant to your workflow.
For example, “Client participated by secure video from home, confirmed privacy, and no technology issues occurred” is often more useful than several sentences describing the platform, camera quality, or routine login process.
How telehealth notes differ from in-person progress notes
The clinical core is the same. You still need a clear record of what happened in the session and why the service was clinically appropriate. The difference is that remote care creates a few additional documentation points.
In an in-person therapy note, the setting is usually assumed. In a telehealth note, the record may need to show that the client was seen remotely, that the client could participate privately, and that any technology problems did not prevent meaningful clinical work. If the connection dropped for 10 minutes, the note should reflect the actual service time and how the session resumed.
Telehealth-specific examples
Short, concrete statements usually work best:
- “Client joined by video from parked car and confirmed they were alone and able to speak privately.”
- “Session began by video; due to audio failure, session continued by phone after client consented to continue.”
- “Client was located at home. Provider reviewed crisis contact plan due to client reporting increased depressive symptoms.”
These details are not filler. They help explain the conditions under which the service occurred and support continuity if another clinician, supervisor, or auditor reviews the record later.
Common mistakes in telehealth therapy notes
Most telehealth documentation problems come from either leaving out remote-session context or overcorrecting by writing too much. Aim for notes that are clear, clinically specific, and easy to review.
Leaving out the client’s location
If a client is remote, their location can matter for safety planning, emergency response, and practice policy. A note that says only “telehealth session completed” may not give enough context. Add a brief location statement, such as “client participated from home” or the more specific format your organization requires.
Documenting interventions too vaguely
“Provided support” does not tell the reader what you did clinically. Instead, name the intervention and connect it to the client’s treatment goals. For example: “Used cognitive restructuring to help client identify catastrophizing related to work feedback and develop a balanced coping statement.”
Forgetting client response
A strong progress note shows more than what the therapist did. It also records how the client responded. Did the client engage, resist, practice the skill, become tearful, report relief, identify a barrier, or agree to a plan? Client response helps support medical necessity and treatment planning.
Writing around risk instead of documenting it directly
If risk was assessed, document it clearly. Avoid vague phrases such as “no concerns” when a more precise statement is available. For example: “Client denied suicidal ideation, homicidal ideation, and self-harm urges. Client identified spouse and weekly therapy as protective factors.”
Documentation tips for faster telehealth notes
Telehealth sessions can move quickly, especially when the client logs in late, has privacy concerns, or spends part of the session troubleshooting audio. A repeatable note structure helps you capture what matters without rewriting each note from scratch.
- Use the same telehealth check-in language each time, then edit as needed. This saves time while still allowing session-specific accuracy.
- Write interventions in active clinical language. Name the method: CBT, DBT skill coaching, motivational interviewing, exposure planning, psychoeducation, grounding, or supportive therapy.
- Link the session to the treatment plan. Identify which goal or symptom area the session addressed.
- Separate facts from interpretation. Record what the client reported, what you observed, and your clinical assessment in distinct sections.
A useful note should answer four basic questions: What brought the client into the session today? What clinical work occurred? How did the client respond? What happens next?
SOAP and DAP options for telehealth therapy notes
You can document telehealth sessions in several common formats. The right format depends on your practice, payer expectations, EHR setup, and clinical preference.
SOAP format for telehealth
SOAP notes organize the session into Subjective, Objective, Assessment, and Plan. This format can work well when you want a clear separation between client report, observable presentation, clinical interpretation, and next steps.
SOAP Telehealth Structure
S: Client report, symptoms, stressors, functioning, and relevant updates.
O: Telehealth modality, presentation on video or phone, engagement, speech, affect, orientation, and other observations.
A: Clinical assessment, progress toward goals, risk level, diagnostic impressions if appropriate.
P: Homework, next session focus, referrals, safety plan updates, and follow-up appointment.DAP format for telehealth
DAP notes organize information into Data, Assessment, and Plan. Many therapists prefer DAP because it is concise but still clinically complete. Telehealth details can be placed at the start of the Data section or in a separate check-in field.
DAP Telehealth Structure
D: Session modality, client location, privacy check, presenting concern, interventions, client statements, and observed behavior.
A: Therapist's clinical assessment, risk, symptom changes, and progress toward treatment goals.
P: Next steps, homework, follow-up care, coordination, and next appointment.Quick checklist before finalizing the note
Before signing the note, scan for missing information rather than rereading every sentence from the beginning. This checklist can help you catch the most common gaps.
- Does the note identify the session as telehealth and state the modality?
- Does it include clinically relevant client location, privacy, consent, or technology details?
- Does it document interventions, client response, progress, risk, and plan?
- Does the note avoid unnecessary personal details that do not support care?
If your note answers those questions, it is more likely to be useful for clinical continuity and easier to review later.
How AutoNotes helps with telehealth therapy notes
AutoNotes helps clinicians create structured, editable progress note drafts from session details. For telehealth work, that means you can start with a template that prompts for the details remote sessions often require, then review and revise the draft before it becomes part of the clinical record.
This is different from using a generic AI writing tool. AutoNotes is built around behavioral health documentation workflows, including individual therapy, intake sessions, assessments, treatment planning, group therapy, and other common clinical services. The goal is not to remove clinician judgment. The goal is to give you a faster first draft that you control.
A practical AutoNotes workflow
- Select the service type, such as individual telehealth therapy or intake.
- Enter the session details you want reflected in the note, including modality, interventions, client response, risk, and plan.
- Review the structured draft for accuracy, tone, clinical fit, and any missing details.
- Edit, finalize, and store the note according to your practice’s documentation workflow.
For clinicians who are behind on notes, this can reduce the blank-page problem. You still decide what belongs in the final note, but you are not starting from an empty screen after a full day of sessions.
Use the template, then build a repeatable workflow
A strong telehealth therapy note is specific, concise, and clinically useful. It documents the remote format without letting technology details take over the note. It also makes the clinical work clear: the client’s concern, your interventions, the client’s response, risk assessment, progress toward treatment goals, and next steps.
If you want a faster way to create editable telehealth note drafts, start your free trial with AutoNotes. You can try it with your own documentation workflow and keep full control over reviewing, editing, and finalizing each note.
