Writing play therapy progress notes can feel overwhelming without a clear structure.
A simple checklist can help ensure you meet clinical, ethical, and funding requirements — while still documenting the heart of the child’s therapeutic process.
Here’s a quick guide to what a complete play therapy progress note should include.
- Date and time of the session
- Length of the session (in minutes)
- Location of session (office, telehealth, school, etc.)
- Who was present (e.g., child alone, caregiver present or partially present)
- Therapist’s full credentials (name, degree, license number)
- Diagnosis (linked to treatment plan)
- Medical Necessity Statement ("Services provided in this session are medically necessary for addressing the client’s diagnosis.")
- Mental Status Exam (MSE) observations (e.g., mood, affect, engagement level, thought process)
- Safety Assessment (risk of harm to self or others)
- Therapist’s signature (electronic or manual)
Note: Most electronic health record (EHR) systems will automatically include session date, time, therapist credentials, and signature fields. However, most insurers require the start and stop time of the session to be written in the body of the note.
- Short narrative description of the session:
- Start and stop time, and setting of the session (telehealth or in person)
- Description of play behaviors in order (what the child engaged with and how)
We like to distill this down to play categories.
- Therapist interventions (reflecting, limit-setting, tracking, etc.)
- Child’s responses to interventions
- TIP: We usually combine those last two points — "Therapist provided CCPT skills and reflections. Client responded by engaging deeper in play with..."
- Progress toward internal growth goals
(e.g., increased flexibility and problem solving evidenced by [play example])
- Progress toward behavioral symptom goals
(may be deferred to caregiver sessions if progress is assessed outside of play therapy sessions by caregiver report: "Progress will be assessed in next parent consult scheduled for X date.")
- Interactive complexity
(note how play was used to facilitate the therapeutic process: "Due to developmental processing needs, play was used to communicate and engage in therapeutic process.")
- Clinical interventions used
(e.g., child-centered play therapy, facilitated co-regulation, provided therapeutic limit-setting)
- Plan for next session
(note when the caregiver session is scheduled; to assess progress toward symptoms and behaviors)
Progress notes shouldn't have every detail of the session, but they should show a clear narrative of what happened, how the therapist supported the work, and how the child responded.
By keeping a structured flow, notes can remain focused, meaningful, and aligned with both clinical and relational goals.
Progress notes shouldn't have every detail of the session, but they should show a clear narrative of what happened, how the therapist supported the work, and how the child responded. By keeping a structured flow, notes can remain focused, meaningful, and aligned with both clinical and relational goals.
