A Mental Health Therapist’s Go-To Guide for Note Templates

What gets documented gets recognized. Therapy notes play a key role in every clinician’s practice – offering a clear, concise record of each session, allowing therapists to monitor treatment effectiveness, decide on future interventions, and satisfy the requirements from an insurance and billing perspective.

With many types of therapy notes available, it can be tough to choose the right one for your practice. From intake notes to progress notes, each type serves a specific purpose and requires certain information. Let’s discuss the various types of therapy notes, their main components, and how to create a template that fits your needs. 

Why are Therapy Notes Important for Therapists in Running Their Practice?

‍Therapy notes help ensure continuity of care, allowing therapists to review past sessions and track client progress over time. This becomes especially important when working with clients who have complex needs or are in long-term treatment.

Besides supporting clinical decision-making, therapy notes serve as a legal record of the services provided. They justify treatment decisions, establish medical necessity, show compliance with ethical and legal standards, and protect therapists in case of a malpractice claim or audit.

Well-written therapy notes also improve communication and collaboration among healthcare providers, such as when referring a client to another specialist or working as part of a multidisciplinary team. They provide a clear and detailed account of the client's treatment history, helping ensure everyone involved in the client's care stays informed.

Therapy Notes are Fit for Purpose

‍With many different therapy note types available, each one serves a specific purpose and comes with its own strengths and limitations. The most common types of therapy notes include:

• Psychotherapy Notes: These private notes are kept separate from the client's medical record and receive strong protection under HIPAA. They include the therapist's thoughts, feelings, and hypotheses about the client and are not typically shared with others unless required by law.
• Therapy Progress Notes: Used for billing, clinical decisions, and as legal documents, these notes are more formal and standardized compared to psychotherapy notes. They are accessible to a broader range of healthcare and administrative personnel for continuity of care.

Progress notes come in various formats, such as SOAP (Subjective, Objective, Assessment, Plan), BIRP (Behavior, Intervention, Response, Plan), and DAP (Data, Assessment, Plan). Each format emphasizes different aspects of the therapy session:

• SOAP: Focuses on the client's subjective experience, observable data, the therapist's assessment, and the treatment plan.
• BIRP: Documents the client's behavior, therapeutic interventions, the client's response, and future plans.
• DAP: Collects relevant data, evaluates progress towards treatment goals, and outlines strategies to support the client.

Other note formats, such as GIRP, CARE, MINT, and FORT, highlight different elements of the therapy session, like client profile, motivation, and therapeutic tools.

When choosing a therapy note type, consider your documentation style, the needs of your practice, and the specific requirements of your clinical setting. The right fit will help you efficiently document client progress, comply with legal and ethical standards, and provide the best possible care.

Intake Note Core Components and Template

‍An intake note plays an important role in the therapy process, serving as the base for understanding a client's background, presenting issues, and initial assessment. When creating an intake note template, consider including the following core components:

Chief Complaint
Sarah M., a 32-year-old woman, reports feeling "overwhelmed and anxious" for the past 6 months. She states, “I just can’t seem to shake the constant worry about everything—work, my family, my health. It's exhausting." Symptoms include excessive worry, difficulty concentrating, irritability, and fatigue. She reports the anxiety is most intense in the evenings and when facing work deadlines. She is seeking treatment to manage her anxiety and improve her emotional well-being.

History

• Current Medications: None currently, though Sarah has taken anti-anxiety medications in the past (e.g., Lexapro) with mild benefit.
• Developmental History: No significant developmental delays noted. Sarah reports a stable childhood, though there were periods of stress due to her parents’ divorce when she was 10.
• Family Psychiatric History: Her mother has a history of depression and anxiety. Sarah's father was diagnosed with generalized anxiety disorder in his 40s.
• Medical History: Sarah is generally healthy, with no chronic conditions. She occasionally experiences tension headaches during times of high stress.
• Medication Trials: Previously trialed Lexapro and Ativan; Lexapro was somewhat effective but had side effects of fatigue, while Ativan was occasionally used for acute anxiety episodes.
• Social History: Sarah is employed full-time as an administrative assistant and lives in a shared apartment with two roommates. She has a supportive social network of friends, though her relationship with her family is strained due to unresolved issues with her mother.
• Substance Use: Social use of alcohol (1-2 glasses of wine per week); no history of risky substance use or smoking.
• Trauma History: No history of significant trauma or abuse, though she mentions "feeling anxious" after witnessing her mother's severe depressive episodes as a child.

Mental Status Exam

• Appearance: Sarah appears well-groomed, appropriately dressed, and maintains good personal hygiene.
• Behavior: She is cooperative, maintaining eye contact throughout the session. No abnormal motor movements or tics observed.
• Alertness: Fully alert and oriented to time, place, person, and situation.
• Speech: Clear, coherent, and appropriately paced.
• Mood: Sarah describes her mood as “anxious and stressed,” with occasional sadness.
• Affect: Slightly constricted but appropriate to content; no signs of excessive emotionality.
• Thought Process: Organized and logical, with no evidence of thought disorder.
• Cognition: Sarah's memory, attention, and concentration appear intact.
• Insight: Good insight into her condition, recognizing her anxiety is impacting her daily functioning.
• Judgment: Good judgment, with no evidence of impulsivity or poor decision-making.

Risk Assessment

• Self-harm: Sarah denies any thoughts of self-harm or suicidal ideation. She expresses that her anxiety and worry make her feel “exhausted,” but she has no history of self-harm.
• Suicidal Ideation: No current suicidal ideation or plans. She is open to treatment and appears motivated to improve her mental health.
• Harm to Others: No history of aggression or harm toward others.
• Protective Factors: Strong social support network from friends, motivation to seek therapy, and insight into her anxiety.
• Risk Factors: Family history of mental health disorders (anxiety and depression) may contribute to her vulnerability, along with ongoing work stress.

Assessment
Sarah M. is presenting with symptoms consistent with generalized anxiety disorder (GAD). Her excessive worry, irritability, fatigue, and difficulty concentrating are having a moderate impact on her ability to function at work and in her social life. Although her symptoms do not appear to be severe enough to warrant immediate crisis intervention, they are persistent and interfere with her daily functioning. She is motivated for treatment and has a history of responding to medication in the past. Her goal is to manage her anxiety better and improve her overall well-being.

Plan

• Immediate Goals:some text
  1. Initiate Cognitive Behavioral Therapy (CBT) to address unhelpful thought patterns and reduce anxiety symptoms.
  2. Introduce relaxation techniques (e.g., deep breathing, progressive muscle relaxation) to manage physical symptoms of anxiety.
  3. Begin mood tracking using daily journaling or a self-help app to monitor anxiety levels and identify triggers.
  4. Assess the potential need for medication management, considering Sarah’s previous experience with Lexapro.
  5. Establish coping strategies for managing work-related stress, including time management techniques and setting boundaries.
• Frequency: Weekly therapy sessions for 8 weeks, with progress review at 4-week intervals.
• Follow-up: Re-evaluate the need for medication (consider a referral to her primary care provider or psychiatrist) based on progress with therapy.
• Additional Support: Provide psychoeducation on anxiety and stress management. Encourage continued use of her support network, particularly in managing family dynamics.

Many electronic health record systems provide HIPAA and insurance-compliant templates for psychotherapy intakes, simplifying the documentation process. Intake forms completed by clients before the session can offer valuable background information, reducing the amount of information to document during the first session.

SOAP Note Core Components and Template

‍SOAP notes provide a structured format for documenting therapy sessions, capturing key information about the client's progress and treatment plan. When designing a SOAP note template, consider including the following core components:

• Subjective (S): This section captures the client's thoughts, feelings, and concerns shared during the session. Use the client's own words as much as possible to accurately convey their perspective. Include their main complaint, relevant history, and any social or environmental factors affecting their well-being.
• Objective (O): Record observable facts and data about the client, such as their appearance, mood, affect, speech, and behavior. Avoid opinions or judgments, focusing on factual observations. In mental health settings, physical examination findings and vital signs may be less relevant but can be included if applicable.
• Assessment (A): Interpret the information from the subjective and objective sections, providing clinical insights. This may include a diagnosis, a summary of the client's progress, and any risk factors or complications. Analyze the client's progress and challenges, making connections between the subjective and objective data.
• Plan (P): Outline the next steps in the client's treatment, including setting achievable goals, identifying interventions, making referrals, and determining follow-up actions. Document any changes to the current treatment plan, such as adjustments to medications, introduction of new coping strategies, or referrals to additional support services. Specify both short-term and long-term goals and interventions.

When creating and using SOAP notes, maintain a consistent format, keep notes concise and clear, and use the past tense for the subjective, objective, and assessment sections. Regularly update the assessment and plan sections to reflect the client's current status and treatment goals. Consider using practice management software or other digital tools to manage and organize SOAP notes, ensuring they are HIPAA-compliant and easily accessible.

BIRP Note Core Components and Template

‍BIRP notes provide a clear framework for documenting therapy sessions, focusing on the client's Behavior, the therapist's Interventions, the client's Response, and the treatment Plan. When designing a BIRP note template, consider including these key elements:

• Behavior (B): Capture both objective observations and subjective accounts of the client's behavior, such as:some text
  • Observable traits, including appearance, body language, verbal communication, alertness, affect, mood, and motor activity.
  • The client's description of their symptoms and feelings outside the session.
  • Context for the behavior, such as the client's mood, environment, or triggers.
• Intervention (I): Describe the therapist's actions in response to the client's behavior, clearly outlining:some text
  • Specific therapeutic techniques and methods used during the session.
  • The theoretical approach or modality employed (e.g., CBT, psychodynamic therapy).
  • Interventions or strategies implemented to address the client's issues.
• Response (R): Note the client's reactions to the therapist's interventions, including:some text
  • Immediate responses to the therapeutic techniques used.
  • Feedback from the client on what they found helpful or unhelpful.
  • Changes or improvements observed in the client's behavior or emotional state during the session.
• Plan (P): Describe the next steps in the client's treatment based on:some text
  • The client's behavior and responses during the session.
  • The therapist's clinical judgment about what may benefit the client's progress.
  • Homework assignments, outside referrals, or follow-up appointments scheduled.

BIRP notes are particularly helpful for monitoring the effectiveness of specific therapeutic techniques and understanding how clients respond to them. These notes rely heavily on clinical theory, making it important for therapists to clearly grasp their theoretical framework to write effective BIRP notes.

Using a BIRP note template streamlines the documentation process, making it easier to track client progress from session to session and ensure thorough recordkeeping. This organized method helps therapists create clear, concise, and informative notes necessary for both clinical practice and billing purposes.

DAP Note Core Components and Template

‍DAP notes offer a structured way to document therapy sessions, focusing on Data, Assessment, and Plan. When designing a DAP note template, consider including these core components:

• Data (D): This section records objective information from the session, such as:some text
  • The client's appearance, behavior, and mental status.
  • Relevant events, changes in symptoms, or progress since the last session.
  • Therapeutic interventions used and the client's response to them.
  • Direct quotes that offer valuable insights into the client's experience.
• Assessment (A): Analyze the collected data to offer clinical insights, such as:some text
  • An analysis of the client's condition, progress, and any issues identified.
  • The therapist's professional judgment on the client's symptoms and progress towards treatment goals.
  • An evaluation of the client's risk level, including potential harm to themselves or others.
• Plan (P): Detail the next steps in the client's treatment, including:some text
  • The date, time, and location of the next scheduled session.
  • Homework assignments or tasks for the client to complete between sessions.
  • Referrals to other healthcare professionals or resources.
  • Adjustments to the overall treatment plan based on the client's progress.

DAP notes assist therapists in systematically documenting client interactions, interpreting data, and planning for future treatment sessions. This format ensures that all relevant information is captured and organized, making it easier to track client progress and make informed treatment decisions.

When creating a DAP note template, aim for a clear and concise structure that allows for efficient documentation while ensuring all necessary information is included. Consider using practice management software or other digital tools to streamline the process and maintain HIPAA compliance.

GIRP Note Core Components and Template

‍GIRP notes offer a structured framework for documenting therapy sessions, focusing on the client's Goals, the therapist's Interventions, the client's Response, and the treatment Plan. When creating a GIRP note template, consider including these key elements:

• Goals (G): Outline the specific therapeutic goals established in collaboration with the client, based on their treatment plan. Include both short-term goals for the current session and long-term goals for the overall therapy process. Ensure goals are client-focused, specific, and measurable, following the SMART criteria (Specific, Measurable, Achievable, Relevant, Time-bound).
• Intervention (I): Document the specific therapeutic techniques, strategies, and discussions used during the session. Detail the types of therapy applied, exercises conducted, and any homework assigned to the client. Highlight the therapist's role and approach in addressing the client's goals, such as using Cognitive Behavioral Therapy (CBT) or mindfulness practices.
• Response (R): Capture the client's immediate and subsequent reactions to the interventions, including changes in behavior, mood, or any insights expressed. Assess the effectiveness of the interventions and the client's engagement with the therapy.
• Plan (P): Outline the future course of action, detailing the next steps in therapy, future goals, adjustments to the treatment plan, and homework or tasks assigned to the client. Ensure continuity and direction for upcoming therapy sessions, maintaining a coherent and progressive treatment plan.

GIRP notes are particularly helpful for creating treatment plan documentation and tracking client progress against specific goals. They assist mental health professionals in staying organized, ensuring accountability, and maintaining continuity of care. This format is especially useful for goal-oriented therapy and long-term treatment monitoring where interventions need adjustment based on client progress.

SIRP Note Core Components and Template

‍SIRP notes provide a structured way to document therapy sessions by focusing on the client's Situation, the therapist's Interventions, the client's Response, and the treatment Plan. When creating a SIRP note template, consider including these key elements:

• Situation (S): Note the client's personal experiences, feelings, and perspectives shared during the session, such as:some text
  • Observations about the client's emotional state, thought processes, and overall well-being.
  • Relevant details provided by the client, including current concerns, updates on progress, symptom changes, stressors, achievements, or setbacks.
• Intervention (I): Describe the therapeutic interventions and techniques used during the session, including:some text
  • Cognitive-behavioral strategies, mindfulness exercises, psychodynamic techniques, or other methods used to address the client's issues and treatment objectives.
  • The reasoning behind selecting each intervention and how it relates to the client's goals.
• Response (R): Document the client's reaction to the interventions, noting:some text
  • Changes in behavior, mood, or insights gained during the session.
  • The immediate effects of the therapeutic strategies and an evaluation of the client's progress.
  • Observable behavior and an assessment of the client's overall response to treatment.
• Plan (P): Describe the plan for future therapy sessions, including:some text
  • Ongoing treatment goals and main focus areas for upcoming sessions.
  • Homework assignments, coping strategies, or exercises for the client to practice between sessions.
  • Arrangements for future appointments and recommendations for external support or community resources, if necessary.

SIRP notes offer several advantages, such as organized documentation, better clinical outcomes, improved communication, and a comprehensive evaluation of the client's therapeutic journey. Consider using practice management software or other AI-enabled digital tools to streamline the process and maintain HIPAA compliance.

PIE Note Core Components and Template

‍PIE notes offer a concise and effective way to document therapy sessions, focusing on the client's Problem, the therapist's Intervention, and the client's response or Evaluation. When creating a PIE note template, consider including these important components:

• Problem (P): Describe the client's presenting issues, symptoms, and treatment goals, including:some text
  • Client-expressed concerns, such as emotions, thoughts, or behaviors.
  • Therapist's objective observations, like changes in mood, appearance, or functioning.
  • Duration and severity of the issue, along with any contributing factors or stressors.
• Intervention (I): Detail the specific therapeutic techniques, strategies, and actions taken by the therapist to address the client's problems, such as:some text
  • Evidence-based interventions used, like cognitive restructuring, exposure therapy, or mindfulness exercises.
  • Psychoeducation provided, coping skills taught, or resources offered to support the client's progress.
  • Homework assignments or tasks given to reinforce learning and encourage practice between sessions.
• Evaluation (E): Assess the client's response to the interventions and track their progress over time, considering:some text
  • The client's report of any changes in symptoms, mood, or behavior.
  • Objective measures or assessment tools used to evaluate treatment effectiveness, like symptom rating scales or progress towards goals.
  • Plans for future sessions, including any adjustments to the treatment plan based on the client's response and needs.

PIE notes help therapists maintain organized and focused documentation, ensuring that important information is captured efficiently. They provide a clear picture of the client's challenges, the interventions implemented, and the client's response to treatment, allowing for better continuity of care and treatment planning.

PIRP Note Core Components and Template

‍PIRP notes offer a structured way to document therapy sessions, focusing on the client's Problem, the therapist's Intervention, the client's Response, and the treatment Plan. When creating a PIRP note template, consider including these key components:

• Problem (P): Pinpoint the client's main concern or issue that is the session's focus. This might include:some text
  • Specific symptoms, troublesome behaviors, or distressing emotions.
  • Situational difficulties or challenges the client is encountering.
  • Direct quotes from the client to provide context and clarity.
• Intervention (I): Record the therapeutic techniques, strategies, and methods used to address the client's problem, such as:some text
  • Specific types of therapy applied (e.g., CBT, solution-focused, or psychodynamic).
  • Discussions, exercises, or activities conducted during the session.
  • Homework assignments or tasks given to the client to reinforce progress.
• Response (R): Describe the client's reaction to the interventions, including:some text
  • Immediate responses, such as insights gained or emotional breakthroughs.
  • Changes in symptom severity or frequency over time.
  • Challenges or difficulties in implementing therapeutic strategies.
• Plan (P): Outline the next steps in the client's treatment, considering:some text
  • Future therapy goals and objectives based on the client's progress.
  • Adjustments to the treatment approach or interventions as needed.
  • Tasks, homework, or self-care activities for the client to complete between sessions.

PIRP notes help maintain a clear, problem-focused approach to therapy documentation. This format allows therapists to efficiently track client progress, tailor interventions to specific issues, and adapt treatment plans as needed.

Couples Therapy Session Note Core Components and Template

‍When designing a template for couples therapy session notes, it's important to capture key information about the couple's dynamics, progress, and treatment plan. Consider including the following core components:

• Session Details: Note the date, time, and duration of the session, along with the names of the participants. Depending on your approach, you may identify one or both partners as clients.
• Themes and Topics: Highlight the main topics discussed during the session and how they connect to the couple's treatment goals. Identify any recurring patterns or themes that emerge, such as communication issues or boundary concerns.
• Observations: Document both objective and subjective impressions of the couple's interactions, including body language, tone, and communication style. Note each partner's mood, participation, and behavior during the session.
• Interventions: Describe the therapeutic techniques and methods used, such as specific exercises, homework assignments, or approaches like emotionally focused therapy. Evaluate how effective these interventions are in addressing the couple's challenges.
• Progress and Goals: Assess the couple's progress toward their therapeutic goals, noting any significant events or breakthroughs. Set individual and couple goals for future sessions, along with interventions designed to help them achieve these objectives.
• Future Plans: Include the date and time of the next session and any plans for upcoming therapy, such as exploring specific topics or assigning activities for the couple to work on together. Note any homework or assignments given to reinforce progress between sessions.

Make sure to maintain confidentiality for both partners and obtain their consent regarding how session notes will be handled, especially if only one member is identified as the client.

Case Management Notes Core Components as Template

‍Case management notes play a key role in documenting a client's therapeutic journey, treatment plans, and progress. When you create a template for case management notes, consider including these components:

• Client Information: Include the client's identifying details, demographics, and relevant background information.
• Session Details: Record the date, time, and location of each session, along with the type of contact (e.g., in-person, telehealth, or phone).
• Subjective and Objective Observations: Document the client's thoughts, feelings, and behaviors, as well as the case manager's objective observations. Use formats like SOAP (Subjective, Objective, Assessment, Plan) to organize this information.
• Treatment Plans and Goals: Describe the client's current treatment plans, goals, and progress towards them. Update these regularly to reflect any changes or adjustments.
• Interventions and Responses: Note progress toward treatment goals, any changes in symptoms or behaviors, the effectiveness of specific interventions (such as therapy or medication), and the client's engagement in services. 
• Significant Events: Identify any important incidents, life changes, or stressors that may affect the client's mental health and well-being.
• Follow-Up Actions: Outline plans for future sessions, referrals to community resources, or coordination with other healthcare providers involved in the client's care.

When writing case management notes, aim for clarity, conciseness, and objectivity. Use a standardized template for consistency and to reduce errors. Maintain client confidentiality by securely storing notes and sharing information only when necessary for the client's care.

Creating Your Own Custom Template

‍While pre-made therapy note templates provide a solid foundation for documenting sessions, creating a custom template tailored to your specific needs and therapeutic approach can significantly improve your note-taking process. By combining elements from various note structures, you can design a template that best fits your client session goals and requirements. Here's how to get started:

• Identify Key Components: Review different note formats like SOAP, DAP, GIRP, and BIRP to determine which sections and elements are most relevant to your practice. Consider including sections for client goals, interventions, progress, and future plans.
• Customize Sections: Modify or rename sections to align with your terminology and therapeutic approach. For example, you might prefer "Interventions" over "Plan" or "Client Response" instead of "Evaluation."
• Include Relevant Fields: Add fields specific to your needs, such as homework assignments, symptom tracking, or intervention effectiveness ratings. This allows you to capture important information consistently across sessions.
• Use Technology: Take advantage of secure, HIPAA-compliant software or digital solutions to streamline your template creation process. Many platforms offer intuitive template builders with drag-and-drop functionality and customizable fields.
• Iterate and Refine: As you use your custom template, note any areas that need improvement or additional fields that would be helpful. Regularly update your template based on your changing needs and client feedback.

The key to creating an effective custom therapy note template is finding a balance between capturing necessary information and maintaining a streamlined, efficient documentation process. Aim for a template that is comprehensive yet concise, allowing you to focus on delivering high-quality care to your clients.

Key Takeaways

‍Therapy notes play a vital role in documenting client progress, guiding treatment decisions, and ensuring continuity of care. When creating or using therapy note templates, consider these key points:

• Choose the right format: Select a note structure that matches your therapeutic approach and the needs of your practice, such as SOAP, BIRP, DAP, or one of many existing standard note templates.
• Customize your template: Adjust your therapy note template to capture the most relevant information for your clients and treatment style by combining elements from different formats.
• Focus on key components: Include sections for client goals, interventions, progress, and future plans to ensure comprehensive documentation.
• Maintain consistency: Use a standardized template across all client sessions to promote clarity and reduce errors.
• Prioritize privacy and security: Ensure that your therapy notes are stored securely and comply with HIPAA regulations, especially when using digital platforms.
• Regularly review and update: Evaluate the effectiveness of your therapy note template periodically and make adjustments based on changing needs and client feedback.