Mental health records contain a detailed picture of your psychological history, from the diagnoses you’ve received to session-by-session notes your therapist writes after each appointment. They include much of what you’d expect in any medical file, plus information unique to behavioral health: risk assessments, therapy progress notes, treatment plans with specific goals, and sometimes input from family members or other providers. Importantly, there’s a legal distinction between your official mental health record and a therapist’s private psychotherapy notes, which are kept separately and have stronger privacy protections.
Intake and Demographic Information
Every mental health record starts with an intake assessment, the detailed evaluation completed during your first visit or admission. This section captures your basic demographic details (age, gender, contact information), the reason you’re seeking treatment, and your history of presenting complaints. It also includes your medical history, prior mental health treatment, substance use history, family psychiatric history, and any current medications.
If you’re being seen at a facility rather than a private practice, your file will also contain a registration number, insurance information, and the specific section or legal basis under which you were admitted. For inpatient stays, the intake record is more extensive and typically documents your living situation, employment status, and social support network.
Diagnoses and Diagnostic Codes
Your record includes formal diagnoses assigned using the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Each diagnosis comes with a specific code that insurance companies use for billing, but it also serves as shorthand for the clinical picture your provider has identified. Common entries range from major depressive disorder and generalized anxiety disorder to more specific conditions like prolonged grief disorder, which requires symptoms lasting at least 12 months after the death of a loved one.
Your provider may also document clinically significant behaviors that don’t fall under a specific diagnosis. The DSM-5-TR includes stand-alone codes for suicidal behavior and nonsuicidal self-injury, allowing clinicians to flag these in your record independently of any psychiatric diagnosis. If your symptoms don’t fit neatly into one category, you might see a residual label like “unspecified mood disorder” noted in your file.
Progress Notes From Each Session
The bulk of most mental health records consists of progress notes, written after each therapy session or psychiatric appointment. These follow standardized formats, and the specific format your provider uses shapes what gets documented.
The most common structure is the SOAP note, which has four parts. “Subjective” captures what you reported during the session: your symptoms, emotions, concerns, and how you say you’ve been doing. “Objective” records what the clinician directly observed, such as your appearance, mood, behavior, and any measurable data. “Assessment” is the clinician’s professional interpretation of how you’re progressing. “Plan” outlines what comes next, including any changes to your treatment approach or goals for upcoming sessions.
Other widely used formats include BIRP notes (Behavior, Intervention, Response, Plan), which emphasize what specific therapeutic techniques were used and how you responded to them, and DAP notes (Data, Assessment, Plan), a more streamlined version. Regardless of format, every progress note documents session start and stop times, the type of therapy provided, and how frequently you’re being seen.
Treatment Plans and Goals
Your record includes a formal treatment plan that lays out the goals of your care. Unlike progress notes, which capture individual sessions, the treatment plan is a living document that gets updated as your needs change. It typically identifies your primary concerns, sets measurable objectives (such as reducing panic attacks from five per week to one), specifies the therapeutic approaches being used, and establishes a timeline for reassessment.
Treatment plans also note the modality of care you’re receiving, whether that’s individual therapy, group therapy, couples counseling, or a combination. If your provider assigns therapeutic homework or tasks between sessions, those may be documented here as well.
Risk and Safety Assessments
Any time a clinician evaluates you for suicide risk, self-harm, or potential harm to others, the assessment and its findings become part of your record. These assessments follow a structured approach, typically using a cascading series of questions: Are you feeling hopeless? Have you had thoughts about taking your life? Do you have a plan? Have you ever attempted suicide before?
The documentation captures your answers, the clinician’s evaluation of your risk level, and any safety measures put in place. These measures might include a safety plan (a written set of steps you agree to follow during a crisis), efforts to remove access to lethal means, or a referral for more intensive care. If warning signs suggest an imminent risk, your record will note whether hospitalization was considered or arranged. Any mention of suicidal thoughts, intent, or plans in a session triggers a documented mental health assessment.
Medication Records
If you take psychiatric medication, your record tracks every prescription, dosage, and change over time. This includes the reason a medication was started, how you responded to it, and any side effects you reported. For certain medications, monitoring is quite specific. Patients on antipsychotics, for example, should have their weight checked at weeks 4, 8, and 12, then quarterly, with a medication switch considered if weight gain exceeds 5%. Movement-related side effects are typically assessed at every visit or at least every six months.
Some medications require even more intensive documentation. Certain newer treatments mandate in-clinic observation periods with vital signs recorded at specific intervals before, during, and after administration. All of this monitoring data becomes part of your permanent record.
Psychological Testing and Assessments
If you’ve undergone formal psychological testing, the results are filed in your record. This includes standardized assessments for conditions like ADHD, autism, learning disabilities, or cognitive impairment. The record will contain the specific tests administered, your scores, and the psychologist’s interpretation of what those scores mean for your diagnosis and functioning. Patient-reported outcome measures, such as depression or anxiety questionnaires you fill out periodically, are also stored here.
Collateral Information From Outside Sources
Mental health providers often gather information beyond what you share directly. In about 70% of clinical encounters, clinicians review your existing medical records. In roughly 30% of sessions, they consult with another mental health provider involved in your care. About 20% of the time, they speak with a family member or caregiver. Less commonly, they may contact your school (around 5% of encounters) or a non-mental-health provider.
Whatever outside information is gathered gets documented in your file. This might include notes from a phone call with your spouse, a report from your child’s teacher, lab results from your primary care doctor, or records transferred from a previous therapist. The source of the information is identified so that future providers can distinguish between what you reported and what came from someone else.
Discharge Summaries
When you complete treatment or leave an inpatient facility, your record includes a discharge summary. This document covers your condition at discharge, the treatment you received, medications prescribed going forward, expected side effects, warning signs of relapse, and recommendations for follow-up care. It also notes the type of discharge: whether it was planned, requested by you, against medical advice, or if you left without permission.
For inpatient stays, the discharge summary is particularly detailed and includes the full course of your hospitalization, from admission through each phase of treatment to the point of release. A copy is typically provided to you and, with your authorization, to a caregiver.
What’s Not in Your Record: Psychotherapy Notes
There’s a critical distinction most people don’t know about. Psychotherapy notes, sometimes called process notes, are not part of your official mental health record. Under federal privacy law, these are defined as a therapist’s personal notes analyzing the content of your conversations during counseling sessions. They must be stored separately from your medical chart.
Your official record contains summaries of your diagnosis, symptoms, treatment plan, progress, and session logistics. Psychotherapy notes contain the deeper, more sensitive material: a therapist’s impressions about what you discussed, their analysis of the therapeutic relationship, or their in-the-moment reflections. Because of their sensitive nature, these notes require your specific written authorization before they can be shared with anyone, including other healthcare providers. This is a higher standard of protection than the rest of your mental health record receives.
Your Right to Access Your Records
Since April 2021, the 21st Century Cures Act has required healthcare organizations to give you immediate electronic access to your clinical notes. This applies to mental health records just as it does to other medical records. You can typically view progress notes, diagnoses, test results, and treatment plans through a patient portal.
There are narrow exceptions. Providers can withhold notes when releasing them would substantially increase the risk of harm to you or someone else, such as in cases of active psychosis or domestic abuse. Psychotherapy notes (the separate, private notes described above) are also exempt from this access requirement.
How Long Records Are Kept
Retention periods vary by state, but a common standard is a minimum of seven years after your last discharge or final visit. For minors, records are kept until the child reaches the age of majority, then for an additional seven years after that. Some states require longer retention, and many providers keep records beyond the legal minimum. If you need copies of old records, contact the facility or provider directly, as records may have been transferred to storage or archived electronically.