The Top Therapy Note Templates with Examples

In Brief

Progress notes play a vital role in every therapist's practice, acting as an essential record of each client's therapy journey. Though there are different types of therapy notes, each with its unique strengths and focus areas, they all aim to document the therapeutic process.

Choosing the right progress note template for your practice can streamline your documentation, ensure you capture all the necessary information, and help you stay organized and compliant. In this article, we'll look at some popular therapy note templates and provide examples to guide you in creating effective and efficient progress notes.

Whether you're an experienced therapist aiming to improve your documentation process or a new practitioner seeking guidance on best practices, learning about the different types of progress notes and how to use them effectively can greatly impact your practice.

SOAP Notes Template and Example

‍SOAP notes are a widely used progress note format that focuses on the client's subjective experience, objective observations, assessment, and treatment plan. SOAP stands for Subjective, Objective, Assessment, and Plan. Here's a breakdown of each component:

Subjective: What the client reports about their thoughts, symptoms, feelings, and experiences
Objective: What the therapist observes in the client's behavior and affect and description of the interventions the therapist used in session
Assessment: The therapist's clinical impressions and diagnosis and a comment on the client’s progress towards their treatment goal.
Plan: The next steps in treatment, including interventions and homework

Here’s an example SOAP Note for a client with anxiety:

S: Client reports feeling overwhelmed and anxious about work deadlines. States, "I can't stop worrying about getting everything done on time." The client reported poor sleep and racing thoughts.

O: Client appears restless, fidgeting with hands. Speech is rapid, and affect is constricted. The therapist provided psychoeducation on cognitive restructuring and facilitated a mindfulness relaxation exercise.

A:The client continues to demonstrate moderate levels of severity with minimal progress towards the treatment goal to improve sleep. Client's anxiety impacts work performance and overall well-being.

P: Continue CBT interventions targeting anxiety management. Introduce relaxation techniques and thought challenging exercises. Assign homework: daily thought record and progressive muscle relaxation. Follow up next week.

DAP Notes Template and Example

‍DAP notes, which stand for Data, Assessment, and Plan, offer a structured and efficient way to document therapy sessions. This template focuses on capturing key information about the client's presentation, the therapist's clinical impressions, and the treatment plan moving forward. Here's a closer look at each component of a DAP note:

Data: Records objective information about the client's behavior, symptoms, affect, and any significant events or changes since the last session. Include direct quotes or paraphrased statements that capture the client's main concerns, functional impairment, or progress.
Assessment: Summarize your clinical impressions based on the data collected. Describe therapuetic interventions provided in session. Analyze the client's current state, any changes in symptoms or functioning, and how they are progressing towards their treatment goals. Consider differential diagnoses and any risk factors.
Plan: Outline the next steps in treatment, including any interventions, homework assignments, or referrals. Set measurable and achievable goals for the client to work on between sessions, and note any changes to the overall treatment plan.

Here’s an example DAP Note for a client with depression:

D: Client arrived on time, appeared tired with flat affect. Reported feeling "stuck" and unmotivated. Stated, "I can't seem to find joy in anything anymore." No suicidal ideation disclosed.

A: The client continues to demonstrate symptoms of depression, including anhedonia, fatigue, poor self-talk, and lack of motivation. Client is processing grief from recent loss and struggling to adapt to life changes, although their symptoms have been present since before the loss of their relationship. The client reports no progress toward completing cleaning tasks at home. The therapist and client reviewed thought journal during session. The therapist gently challenged distorted thought patterns and offered cognitive reframes. Reviewed behavioral activation strategies with the client.

P: Continue CBT interventions and explore meaning-making in the context of loss. Encourage behavioral activation and self-care activities. Assign homework: daily mood tracking and engaging in one pleasurable activity per day. Monitor for suicidal ideation and reassess next session.

BIRP Notes Template and Example

‍BIRP notes, which stand for Behavior, Intervention, Response, and Plan, offer a structured method for documenting therapy sessions that highlights observable client behaviors and their reactions to interventions. This format proves particularly useful in behavioral health and substance abuse treatment settings. Here's a breakdown of each component:

Behavior: Note the client's specific, observable actions, statements, and symptoms during the session. Include both objective observations and subjective reports, such as direct quotes that capture the client's experiences.
Intervention: Record the therapeutic techniques, modalities, and interventions used to address the client's needs and work towards their treatment goals. Connect each intervention to the relevant objectives and explain the reasoning behind your approach.
Response: Describe the client's reactions, insights, and engagement in response to the interventions applied. Note any resistance, breakthroughs, or challenges the client encountered, and comment on their progress towards treatment goals.
Plan: Outline the next steps in treatment, including short-term and long-term goals, homework assignments, and any necessary adjustments to the treatment plan. Discuss future session scheduling and any needed referrals or consultations.

Here’s an example BIRP Note for a client with substance use disorder:

B: Client arrived on time, appeared agitated, and reported strong cravings for alcohol. Stated, "I almost relapsed last night after an argument with my spouse."

I: Used ACT techniques to support the client in increasing thought defusion skills in relation to interactions with their spouse. Taught deep breathing exercises for managing cravings. Reviewed relapse prevention plan and identified potential triggers.

R: Client actively participated in the discussion and acknowledged the need for additional coping strategies. Practiced deep breathing during the session and reported a decrease in cravings. Expressed commitment to treatment goals of maintaining sobriety.

P: Continue developing relapse prevention skills and enhancing distress tolerance. Assign homework: practice deep breathing daily and update the relapse prevention plan. Schedule a couples therapy session to address relationship stressors. Follow up next week.

GIRP Notes Template and Example

‍GIRP notes, which stand for Goals, Interventions, Response, and Plan, offer a structured way to document therapy sessions, ensuring that each session stays focused and aligns with the client's treatment objectives. This format works well in multidisciplinary settings, as it promotes effective communication among healthcare providers. Here's a breakdown of each component:

Goals: List the specific, measurable, attainable, relevant, and time-bound (SMART) objectives that the client and therapist have agreed upon. Include both short-term and long-term goals.
Interventions: Describe the techniques and methods the therapist used in session to help the client achieve their goals.
Response: Record the client's response to the interventions, including progress, attitude, and behavior during the session. Note whether the client appeared engaged, guarded, or struggled with specific interventions. Make a note on the client’s progress toward their treatment goal.
Plan: Based on the client's response and other information from the session, outline the next steps for ongoing treatment, including follow-up items, homework assignments, future sessions, referrals, or new goals.

Here’s an example GIRP Note for a client with social anxiety:

G: The client will practice one anxiety management strategy per day.

I: The therapist used cognitive behavioral techniques to identify and challenge negative thought patterns. Conducted role-playing exercises to practice responses in social scenarios. Facilitated deep breathing and progressive muscle relaxation exercises to support client’s progress toward goal.

R: Client reported increased confidence after role-playing but stated they struggled with deep breathing during relaxation techniques due to racing thoughts. The client reported some progress toward goal of incorporating anxiety management strategies as they went on 2 walks last week.

P: Schedule next session for Thursday at 3 pm. Assign daily practice of relaxation techniques as homework. Plan to address specific anxiety-triggering social scenarios in future sessions.

PIRP Notes Template and Example

‍PIRP notes, which stand for Problem, Intervention, Response, and Plan, offer a structured and efficient method for documenting therapy sessions. This format highlights the client's specific challenges, the therapist's targeted interventions, the client's response to these interventions, and the plan for future sessions. Here's a breakdown of each component:

Problem: Clearly state the main issue or concern the client faces, using their own words when possible. Include relevant symptoms, behaviors, emotions, or situational difficulties.
Intervention: Describe the therapeutic techniques, methods, or approaches used to address the client's problem. Connect each intervention directly to the identified treatment goal and use action words to describe your work.
Response: Detail the client's reaction to the interventions, noting any immediate or long-term changes in behavior, emotions, or perspective. Evaluate how the interventions affect the client's progress toward the treatment goal.
Plan: Outline the next steps in treatment, including any adjustments to the approach, homework assignments, and future session goals. Note any referrals or follow-up tasks.

Here’s an example PIRP Note for a client with anger management issues:

P: Client reports frequent outbursts of anger, leading to conflicts at work and home. States, "I feel like I'm constantly on edge, ready to explode."

I: Taught deep breathing and progressive muscle relaxation techniques to reduce physiological arousal. Explored triggers for anger and discussed alternative coping strategies, such as developing a meditation practice, listening to music, and walking away from confrontations.

R: Client practiced relaxation techniques during the session and reported a decrease in tension. Identified two recent anger triggers and brainstormed healthier responses for future situations. The client reported no progress toward their treatment goal of decreasing angry outbursts at home.

P: Continue practicing relaxation techniques daily. Assign homework: keep an anger journal to track triggers and responses. Role-play assertive communication in the next session to address interpersonal conflicts. Follow up in one week.

PIE Notes Template and Example

‍PIE notes, which stand for Problem, Intervention, and Evaluation, offer a concise and structured way to document therapy sessions. This format helps therapists quickly capture the key elements of a session, making it easier to track client progress and adjust treatment plans as needed. Here's a breakdown of each component:

Problem: Clearly state the main issue or concern the client brings up during the session. Include relevant symptoms, behaviors, emotions, or situational difficulties, using the client's own words when possible.
Intervention: Describe the therapeutic techniques, methods, or approaches used to address the client's problem. Connect each intervention directly to the identified treatment goal and use action words to describe your work.
Evaluation: Assess how effective the interventions were and observe the client's response. Note any immediate or long-term changes in behavior, emotions, or perspective, and evaluate how the interventions affect the client's progress. Include a comment on the client’s progress toward their treatment goal and plans for future sessions based on the evaluation.

Here’s an example PIE Note for a client with anxiety:

P: Client reported feeling overwhelmed and anxious due to work pressure and deadlines. The client stated they experience difficulty sleeping and constant worry about work performance.

I: Introduced time management techniques and mindfulness exercises to reduce stress and anxiety. Practiced deep breathing and guided visualization to manage immediate feelings of anxiety. The client reported some progress toward goal to use meditation before sleep each evening.

E: Client reported a slight reduction in anxiety levels during the session (6/10 at end, compared to 8/10 at beginning). Client reported appreciation for learning techniques and committed to daily practice. Plan to review progress in applying techniques next session.

CBT Note Template and Example

‍CBT notes can be written using various progress note formats, such as SOAP, DAP, or BIRP, depending on your preference and the specific requirements of your practice. The key is to ensure that your notes capture the important elements of a CBT session, including the client's thoughts, emotions, and behaviors, as well as the interventions used and the client's response to them.

Here's an example of a CBT progress note using the SOAP format:

S: Client reported feeling anxious and overwhelmed due to work-related stress. The client reported they continue to have difficulty relaxing due to fears of being fired. Identified negative automatic thoughts, such as "I'm not good enough" and "I'll never be able to handle this."

O: Client appeared tense and fidgety, with a worried facial expression. Engaged in the session and actively participated in discussions and exercises. The therapist provided psychoeducation on cognitive distortions and supported the client in identifying thinking mistakes they engage in. During the course of the session, the client was able to identify that their fear of being fired is unfounded by evidence.

A: The client continues to report that negative automatic thoughts contribute to increased anxiety and avoidance behaviors. The client reported minimal progress toward treatment goal of using mindfulness exercises outside of session to manage anxiety.

P: Introduce cognitive restructuring techniques to challenge negative thoughts. Assigned homework: thought record to identify and reframe negative cognitions. Plan to introduce relaxation techniques and problem-solving strategies in future sessions.

When documenting CBT sessions, consider the following:

Therapeutic techniques: Specify the CBT interventions used, such as cognitive restructuring, behavioral activation, or exposure therapy.
Client insights: Highlight any significant realizations or breakthroughs the client experienced during the session.
Homework assignments: Clearly outline any tasks or exercises the client is expected to complete between sessions, as these are important for reinforcing skills and promoting progress.

Remember to maintain clear, objective language and ensure that your notes are concise yet comprehensive. Regularly review and update the treatment plan based on the client's progress and work with the client to set achievable goals to guide their treatment.

Couples Therapy Note Template and Example

‍Couples therapy notes can be written in two ways. The first way is to have an identified client whose mental health symptoms are creating functional impairment in the relationship. Treatment is provided in the context of couples therapy to best meet the client’s needs. An example of this is a relationship where one partner is avoiding engaging in physical intimacy due to symptoms of trauma from past sexual abuse. A couples therapist may work with one partner on managing their symptoms and communicating their feelings and help the other partner in understanding what their loved one is going through and how to best support them. In these cases, notes are generally focused on the client with the presenting symptoms just as they would be in an individual therapy session, only with the acknowledgement of the loved one also present in the session.

Other times, couples therapy notes focus on the dynamics and interactions between partners, rather than just one person's experiences. These notes should capture the couple's communication patterns, shared goals, and progress in therapy.

When documenting a couples therapy session, consider including the following elements:

Session summary: Provide a brief overview of the main topics discussed, any significant events or changes since the last session, and the couple's overall progress towards their goals.
Interaction patterns: Observe any recurring themes or patterns in the couple's communication style, such as interrupting, defensiveness, or active listening.
Individual contributions: Note each partner's role in the discussion, their emotional state, and any insights or breakthroughs they experienced during the session.
Interventions and homework: Document the specific techniques or interventions used, such as reflective listening or conflict resolution exercises, and any homework assignments given to the couple.

Here’s an example Couples Therapy Note:

Session Date: 2024-12-10 Participants: John and Sarah, married for 5 years

Session Summary: John and Sarah talked about ongoing communication issues and a recent argument over household responsibilities. Both partners expressed a desire to improve their conflict resolution skills and create a more balanced division of tasks although minimal progress has been made toward their goal of implementing skills learned in session to their home life.

Interaction Patterns:
- The therapist observed that John tends to withdraw during conflicts, while Sarah becomes more vocal and expressive.
- The therapist facilitated an exercise to promote use of communication skills. During this exercise, both partners appeared to struggle to listen actively and validate each other's perspectives.

Individual Contributions:
- John acknowledged his tendency to avoid difficult conversations and expressed a willingness to work on assertive communication.
- Sarah recognized her role in escalating conflicts and committed to practicing empathy and patience.
-Both individuals actively engaged in discussion about how the cultures of the families they grew up in continue to affect their communication styles and expectations of one another. This discussion appears to help foster a new understanding and more compassion and empathy for each other.

Interventions and Homework:
- Introduced the speaker-listener technique to encourage active listening and turn-taking during discussions.
- Assigned homework: Each partner will take turns expressing their feelings about a specific issue while the other practices reflective listening. The couple will create a list of household tasks and negotiate a fair distribution of responsibilities.

Plan:
- Continue working on communication skills and conflict resolution strategies that honor and recognize each person’s cultural norms.
- Explore the cultural impact of individual coping mechanisms and how they impact the relationship.
- Monitor progress on homework assignments and provide feedback in the next session.

Group Therapy Note Template and Example

‍Group therapy notes differ from individual therapy notes because they focus on the dynamics and interactions among group members, as well as each individual's progress within the group setting. When documenting a group therapy session, it's important to maintain client confidentiality, use an objective tone, address the client’s progress toward their treatment goal, and describe the methods and interventions used during the session.

Key elements to include in a group therapy note:

Group summary: Begin with an overview of the session, including the group name, topic, date, time, counselor's name, and number of attendees. This section can be the same for all clients in the group.
Individual client information: Include identifying information, mood, appearance, behavior, and interactions for each client. Focus on behaviors or interactions that directly impact this client’s therapeutic process.
Progress towards goals: Record each client's progress toward their individual treatment goals within the group context.
Interventions and plans: Describe the techniques used, such as role-playing or group discussions, and any plans or strategies developed during the session.

Here’s an example Group Therapy Note:

Group Name: Anxiety Management Group
Date: 2024-12-10
Time: 10:00 AM - 11:30 AM
Counselor: Jane Smith, LCSW
Number of Attendees: 6

Client: John Doe
ID: 1234567
DOB: 1990-01-01

Mood and Appearance: The client appeared calm and engaged in the session. He maintained good eye contact and participated actively in discussions.

Behavior and Interactions: The client shared his experiences with anxiety in social situations and listened attentively to others' stories. He offered support and feedback to group members and demonstrated empathy. The client appeared with tears in his eyes when another group member shared about feelings of loneliness and isolation. The client shared that he used to feel very similarly up until very recently and expressed hope for his peer.

Progress Towards Goals: John reported using deep breathing techniques learned in previous sessions to manage his anxiety during a recent job interview. He expressed feeling more confident in his ability to cope with anxiety-provoking situations.

Interventions and Plans: The group practiced assertive communication through role-playing exercises. John participated in a scenario where he assertively expressed his needs to a coworker. He committed to practicing assertive communication in real-life situations and reporting back to the group next week.

Remember to keep your notes clear, concise, and compliant with HIPAA regulations and insurance requirements. Use templates to maintain consistency and efficiency in your documentation process.

Customizing Your Own Mental Health Progress Note Example

‍While using established templates like SOAP, DAP, or BIRP can provide a solid foundation for documenting therapy sessions, creating a custom progress note format tailored to your practice's unique needs offers flexibility and efficiency. When designing your own mental health progress note template, consider including the following key elements to ensure thorough, compliant documentation:

Patient Information and Session Details: Include the date, duration, and any relevant diagnostic and service codes for easy reference and billing purposes.
Establish Medical Necessity: Record the reasons client is seeking support through identifying functional impairments, reported symptoms and the client's direct quotes.
Intervention and Response to Intervention: Describe the therapuetic interventions and modalities used in the session and how these relate to the identified treatment goals. The client’s response to the intervention can also be helpful to include.
Progress Toward Treatment Goal: A sentence or two on the client’s progress, or lack thereof, toward the treatment goal, is a staple of every progress note.
Plan for Future Sessions: Outline homework assignments given to the client and the plan for the next session, ensuring alignment with the overall treatment objectives.

To create an efficient and effective custom progress note template, consider these strategies:

Identify Key Sections: Determine the main components that your notes must include based on your practice's requirements, such as a specific diagnosis format (e.g., ICD-10 or DSM-5), safety issues, or medication information.
Use Checkboxes and Dropdown Lists: Incorporate these features to quickly select common assessment terms and descriptors, reducing typing time and ensuring consistency.
Create Starter Phrases: While each note should be uniquely written for the individual session, developing a list of frequently used sentences and phrases for common topics can help automate your thought process and minimize mental effort when writing notes.
Maintain Consistency: Stick to your custom template to ensure all important information is included and to streamline the documentation process over time.

Here’s an example custom mental health progress note:

Date: 2024-12-10
Duration: 60 minutes
Service Code: 90837

Establish Medical Necessity: The client reported feeling overwhelm and anxious due to work related stress. Reported their boss recently informed them of potential layoffs on their team. The client since this discussion they have been experiencing restlessness and unable to complete tasks at work in a timely manner, which has increased their anxiety.

Intervention and Response to Intervention: The therapist utilized ACT mindfulness strategies and metaphors to support them in increasing acceptance skills. Engaged client in structured problem-solving to manage anxiety in healthier ways. Client expressed sense of relief during conversation on problem-solving and expressed goal to do a new draft of their resume this week.

Progress Toward Treatment Goal: The client reported they regressed in their progress toward their treatment goal to engage in healthy coping skills daily, noting they have been drinking 2-3 glasses of wine each night instead of exercises as they normally do.

Plan for Future Sessions: Consider introducing thought defusion techniques to client at next session, depending on their emotional state and status with their job. Continue providing support around engaging in healthy coping skills.

Customizing your mental health progress notes allows you to create a format that aligns with your practice's workflow, ensures compliance, and promotes efficient documentation to support high-quality client care.