AI Progress Notes for Therapists: A Starter Guide for Small Practices, With Client Consent and HIPAA Done Right

Updated 2026-10-22 · Some links may be affiliate links. Disclosure

Most therapists don’t need to be told that notes eat their evenings. AI note tools now draft a progress note from a session recording, from a few lines you dictate, or from a short typed summary, and you edit and sign it. Done well, that gives you time back. Done carelessly, it puts a recording of the most private conversation your client has had into a system nobody vetted, with no consent on file.

This guide is for solo and small practices. It ranks five tools that actually exist and do this job, explains the one decision that matters most (record the session, or don’t), and walks through the HIPAA, consent and professional-ethics steps to settle before the first AI-drafted note goes into a chart.

The HIPAA vendor checks here are the same ones we use for dental and medical front offices; if you also run reminders or phones, see our AI appointment reminders guide and AI scheduling and phones guide.

Not legal or clinical advice. HIPAA and Part 2 are summarized from HHS; recording-consent law and AI-disclosure rules vary by state, and your licensing board and professional code control. Check them before you go live.

Ranked picks for AI progress notes

Why this order: For a small practice, the biggest risk isn’t note quality, it’s adding a new vendor that holds session content. If your EHR already offers AI notes, start there: the drafts land in the chart you already use, under a vendor relationship (and BAA) you already have. SimplePractice is first because it’s the broadest built-in option: telehealth, in-person and dictation, and couples and groups. Its catch is a June 2026 change: new Note Taker users are opted in by default to SimplePractice keeping a de-identified copy of transcripts to improve the product, which you can switch off (SimplePractice). TherapyNotes is a close second and the best fit if you don’t want to record at all, since its core feature works from your own summary; it doesn’t yet support couples or group notes (TherapyNotes FAQ). If your EHR has no AI notes, or you see clients on Zoom, Upheal is the best standalone start: it has a free no-recording tier and a flat $39 plan. Mentalyc costs more for full caseloads, but its Pro plan and up handle child, couple and family sessions (group notes on Super and Team) and tie notes to treatment-plan goals. Blueprint is cheapest for a light caseload, but its pricing page lists more than one option for using it alongside your EHR, so get the price in writing.

None of these replace your judgment. SimplePractice itself warns that AI “may generate notes with mistakes, missing details, incorrect statements, accidental bias, or irrelevant information” and requires review before saving (SimplePractice).

Step 1: Decide: record, or summarize?

Every tool above can draft a note without recording the session: SimplePractice and Upheal from dictation, TherapyNotes from a typed summary, Mentalyc and Blueprint from dictation or a typed summary. That mode saves less time, because you still have to recall the session, but nothing from the room itself leaves your head. Recording saves more time and captures more detail, and it brings in consent-to-record law, transcript retention and a higher bar for client trust.

A sensible path for a small practice: start with summary or dictation mode for two weeks, then offer recording only to clients who opt in. Some clients will say no, and that should never affect their care.

Step 2: Get the BAA, and read what happens to audio and transcripts

1. The vendor is your business associate. Any company that creates, receives, maintains or transmits protected health information on your behalf is a business associate, and you need a business associate agreement with the terms HIPAA requires at 45 CFR 164.504(e). The vendor must also have BAAs with its own subcontractors that touch your data (HHS business associate guidance).
2. What the vendors say:
   • TherapyNotes: TherapyFuel is covered under its BAA with you, and its AI vendors must have BAAs with TherapyNotes limiting data use to the service, “not train their tools” (TherapyNotes FAQ).
   • SimplePractice: Note Taker staff access is governed by its BAA; its AI runs on Anthropic’s model through AWS, both under business associate obligations (Note Taker FAQs, transcript retention).
   • Upheal: publishes a click-to-accept BAA and says it uses only de-identified, aggregated data to improve the app (Upheal BAA).
   • Mentalyc: says every account is covered by a BAA created at signup, downloadable from your profile (Mentalyc).
   • Blueprint: says a BAA is included in its terms and a signable copy is available (Blueprint).
3. Know the retention rules, in writing. This is where the tools really differ:

Decide your own rule (for example, “no audio saved, transcripts deleted when the note is signed, retention for product improvement off”) and set every clinician’s account to match. In SimplePractice there’s no practice-wide retention switch; each clinician sets their own (SimplePractice).

Keep session content out of general chatbots. A general AI assistant isn’t a substitute for these tools. OpenAI, for example, says self-serve ChatGPT Business is not the route for BAAs; those require a contracted offering (OpenAI help). Without a BAA, client information doesn’t go in.

Step 3: Keep progress notes and psychotherapy notes apart

HIPAA gives extra protection to psychotherapy notes: a mental health professional’s notes analyzing the conversation in a session, kept separate from the rest of the record. They exclude session times, modalities, medication, test results and summaries of diagnosis, functional status, treatment plan, symptoms, prognosis and progress. With few exceptions, disclosing them requires the client’s authorization (HHS; 45 CFR 164.501).

An AI-drafted progress note is a summary of symptoms, interventions and progress, so it belongs in the record, which clients, payers and sometimes courts can see. Two practical rules follow: edit out anything the AI pulled from the session that doesn’t need to be in the record (third-party names, verbatim disclosures that aren’t clinically necessary), and don’t paste your private process notes into an AI summary box if you keep them as psychotherapy notes.

Step 4: If you treat substance use, check 42 CFR Part 2

Part 2 applies to federally assisted programs that provide substance use disorder diagnosis, treatment or referral for treatment. With limited exceptions, those records can be shared only with written patient consent or a court order, and some Part 2 requirements also reach organizations that receive the records, including HIPAA business associates and qualified service organizations. The 2024 final rule’s compliance date was February 16, 2026 (HHS Part 2 overview). If your practice is or might be a Part 2 program, ask each vendor in writing whether it supports Part 2 records and what agreement it signs, and have counsel review before you record any SUD session.

Step 5: Get informed consent, in writing, before the first AI note

• Professional bodies expect it. The American Counseling Association says counselors should “clearly inform clients about the use of AI tools” and “obtain explicit informed consent from clients for the use of AI-assisted tools” (ACA). The American Psychological Association’s 2025 ethical guidance says psychologists should obtain informed consent “by clearly communicating the purpose, application, and potential benefits and risks of relevant AI tools” (APA), and its guidance on AI scribes recommends an informed consent process and documentation policy for scribe use (APA).
• Recording law varies by state. SimplePractice notes that “a number of states” require all parties’ consent to record a session (SimplePractice). Get consent to record even where one-party consent is legal; it’s the ethical baseline above.
• Start from a vendor template, then fix it. SimplePractice has a “Consent for Use of AI Tools with De-Identified Transcript Retention” form, TherapyNotes has a consent template in its library, and Mentalyc includes a client AI consent template. TherapyNotes itself says it “cannot guarantee” its template meets your requirements (TherapyNotes). Make sure your form says, in plain language: which tool, whether the session is recorded, what happens to audio and transcripts and when, whether de-identified data is kept, that you review every note, and that the client can say no or withdraw at any time without affecting care.
• Ask again for couples, families and groups. Every adult in the room needs to agree, and one “no” means no recording for that session.
• Note it in the chart. Record the client’s choice and revisit it if your vendor changes its data practices, as SimplePractice did in June 2026.

Step 6: Set up the tool to write your notes, not generic ones

• TherapyNotes: pick the primary treatment approach, then complete mental status, risk assessment and interventions before generating; the FAQ says this gives better notes (TherapyNotes). Use Clinical Voice Settings to set “client” vs. “patient,” pronouns, tone and length.
• SimplePractice: Note Taker copies the format and style of your last progress note for that client, so make sure that note is one you’d want copied (SimplePractice).
• Upheal, Mentalyc, Blueprint: choose your note template (SOAP, DAP, BIRP and so on) and your modality, and set up the transfer into your EHR so the signed note ends up in the chart, not only in the AI tool.

Step 7: Review every note like it was written by a new intern

Before you sign, check:

1. Nothing invented. Interventions you didn’t use, homework you didn’t assign, quotes the client didn’t say.
2. Risk is accurate. If suicidal ideation, self-harm, abuse or threats came up, the note says exactly what was assessed and what you did. Never let AI wording soften or overstate risk.
3. Medical necessity is real. Tools like Upheal and Mentalyc write toward payer criteria. Make sure what’s written matches what happened; you sign it, and you answer for it.
4. Minimum necessary. Remove details that don’t need to be in a record others may read.
5. Diagnosis is yours. ACA says counselors should not use AI as the sole tool for diagnosis and assessment (ACA).

Sign notes promptly. SimplePractice deletes the transcript and draft if the note isn’t signed within 7 days, and you’d have to write it by hand (SimplePractice).

Step 8: Measure after 30 days

Track minutes per note (before vs. after), notes signed same-day, how many clients declined recording, and how many AI drafts needed major edits. Vendor time-savings claims and testimonials aren’t your results. If drafts keep needing heavy rewrites, switch to summary mode or try another tool during its trial: SimplePractice and TherapyNotes offer trials, Upheal has a free plan and a 30-day money-back guarantee, Mentalyc a 14-day trial, Blueprint free starter sessions.

Vendor question list

• Will you sign (or show me) a BAA that covers the AI features, audio, transcripts and your AI subprocessors?
• Exactly when are audio and transcripts deleted? Is any copy kept, even de-identified, and can I turn that off for every clinician?
• Is my clients’ data used to train or improve any AI model?
• Can I draft notes without recording (dictation or typed summary)?
• Does it support couples, family and group sessions, and which note templates?
• Which EHRs does it send notes to, and does the signed note live in my chart?
• If we are a 42 CFR Part 2 program, what agreement do you sign and how do you handle SUD records?
• What’s the full price per clinician, including caps on notes per month, add-ons and promotional pricing that ends?

Quick checklist

• Decided: summary/dictation only, or recording with opt-in
• BAA in hand and covers the AI features
• Retention settings match our written rule, for every clinician
• Psychotherapy notes kept out of AI tools and separate from the record
• Part 2 question answered (or not applicable)
• Written AI and recording consent on file for each client, every adult in joint sessions
• Note template, approach and voice settings configured
• Every AI draft reviewed for accuracy, risk and minimum necessary before signing
• 30-day review of time saved, consent declines and edit burden

Tools in this guide

• Blueprint: Part-time clinicians and lighter caseloads who'd rather pay per session than a flat monthly fee.
• Mentalyc: Clinicians who see couples, families, children or groups, or want notes linked to treatment-plan goals, while keeping their current EHR.
• SimplePractice Note Taker: Practices already on SimplePractice that want AI notes inside the chart without adding a second vendor.
• Upheal: Solo therapists who want a standalone AI note tool that works with any telehealth platform, with a free no-recording option to start.
• TherapyNotes TherapyFuel: Practices already on TherapyNotes, and clinicians who want AI help without recording sessions.

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• How a Dental Office Automates Scheduling and Phones With AI
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