How to Write Therapy Notes: Examples, Templates and Tips

Therapy notes are called differently: progress notes, psychotherapy notes, counseling notes, and therapist notes. You can choose any type you like, but the idea stays the same: whether you’re an LCSW, psychologist, or counsellor, clinical documentation is an integral part of your work and must be done and kept right.

This complete guide covers note-taking formats, worked examples of counselling session notes, treatment planning, and best practices for mental health professionals.

Let’s start with a quick glossary to eliminate vagueness in definitions.

Therapist Notes, Progress Notes and Psychotherapy Notes Compared

Why Keep Progress Notes and Session Records?

Notes are designed to keep track of patient progress and regression, make alterations to the current treatment plan, and keep billing information. They are necessary if we talk about a clinician with a big list of patients and a waiting list.

There are some additional reasons to keep therapy session notes. They include:

• Support supervision-intervention. Notes help other providers understand the client’s care if referrals or transitions occur.
• Demonstrate medical necessity. Documentation protects both client and clinician if records are reviewed by insurance companies and trials.
• Ensure safety. Record risk factors, self-harm concerns, or the need for a safety plan.

You see, it is impossible to imagine a meaningful counseling session without relevant information.

What Should I Include Inside Therapy Notes?

Let’s divide therapy progress notes according to the type of session, whether it’s a first appointment or a follow-up visit.

#1. Initial Session Notes

When you see your client for the first time, your attention should be focused on comprehensive background and baseline information:

• Client acquisition (recommendations, found on the internet, via social media, etc.). Client acquisition is a core channel of receiving potential clients, so we strongly recommend not ignoring it.
• Request, goals, and expectations. The first therapy session provides you with subjective information about the client's condition. Write it down as a direct quote.
• Presenting issues and depressive symptoms, panic attacks, or other mental status exam findings.
• Client reports about stressors, negative thought patterns, and coping skills.
• Biographical information (born/married). As part of a group therapy, this information will be useful for creating the appropriate patient groups.
• Your assumptions about typical trigger situations and automatic thoughts and beliefs, if any, surfaced at the start.
• Initial interventions or CBT techniques introduced in session.
• Summary of the client’s response and emotional tone.

As you can see, the major task of the first visit is collecting the maximum information about a client, creating (at least approximately) a future plan of treatment and choosing an appropriate form of note-taking for this very situation.

#2. Follow-Up or Subsequent Sessions

You've taken a first look at a person and learnt about his background and symptoms. The next step is a follow-up appointment where it would be prudent to focus on change and track progress:

• Changes in well-being, thoughts and behavior since the previous session (sleep, mood, functioning).
• Client’s behavior and eye contact during discussion.
• What interventions were used this time (CBT, relaxation techniques, or psychoeducation)?
• Client’s response and engagement with assigned coping strategies.
• Treatment plan adjustments or new treatment goals.
• Homework assigned for the next session.
• Clinician’s impression and continuity plan.

Taking all of this information into consideration will contribute to the high quality of your own notes. We have made a compilation of the most common types of notes for your convenience.

Examples of Counselling Session Notes Formats

Different note-taking systems suit different clinicians and settings. The most popular are SOAP, DAP, BIRP, and PAIP. Each organises information slightly differently but shares the same intent: to document clearly, concisely, and meaningfully.

Below are explanations and realistic examples for each format.

#1. SOAP Notes

SOAP stands for Subjective, Objective, Assessment, and Plan. It’s one of the most widely used structures in healthcare, especially during the first sessions. The essence and goals of this type of progress recording are determined by four essential elements, similar to how different types of punctuation bring structure and clarity to written language.

Clinicians seeking structure in their documentation often check out SOAP note templates for mental health to serve as helpful guides.

SOAP note example (anxiety case):

#2. DAP Notes

DAP stands for Data, Assessment, Plan. Some clinicians expand it to DARP, adding Response. It simplifies the SOAP format and is often used during follow-ups as a concise client progress note template.

DAP note example (depression case):

#3. BIRP Notes

BIRP stands for Behavior, Intervention, Response, and Plan. It is widely used in behavioral health and community mental health settings.

BIRP note example (relationship stress case):

Electronic health records software (EHR) with built-in templates and auto-fill can save up to 2 hours each week for note-taking:

#4. PAIP Notes

PAIP represents Problem, Assessment, Intervention, and Plan. Use it if you want to focus on defining the presenting issue first, then analyse and address it.

PAIP note example (grief case):

Tips for Writing Effective Therapist Notes

1. Write promptly after each session while the details are still fresh.
2. Stick to what actually happened or was said. Save your interpretations or insights for the Assessment section.
3. Replace labels (“difficult client”) with observations (“client became withdrawn”).
4. Record behavior without adding opinions or assumptions.
5. Include quantifiable details when possible, like scores on a scale, the number of times a behavior occurred, or direct quotes from the client.
6. Never include identifying information about third parties or sensitive details outside the client’s treatment.
7. Periodically reread notes to identify treatment patterns and outcomes.

How to Choose the Right Note Format for Your Mental Health Practice

Obviously, there are a lot of types of mental progress notes that can meet the demand of every private practice professional. We have compared the most popular ones to help you pick your favourite:

Save 2 Hours per Week with Electronic Note-Keeping

Using Medesk medical notes software designed for therapy and counselling makes your workflow faster, safer, and more patient-focused:

• Save hours each week by using ready-made, customisable consultation-note templates (SOAP, DAP, free-form) plus auto-fill of patient and provider data.
• Speed up onboarding and follow-up with online intake forms shared ahead of time. The results: clients arrive ready, informed, and engaged, and you witness a notable drop in no-shows.

• Better structure = clearer treatment plans and better outcomes. Digital therapy notes templates bring consistency. Whether it’s SOAP, DAP, BIRP, or PAIP formats, you’re capturing the right data in the right place. That consistency builds professional credibility and client trust, which matters for both clinical outcomes and retention.
• Less risk, more control with everything stored in one encrypted, controlled system. You reduce risks associated with paper files (lost, damaged, unauthorised access).
• Scale your practice without being drowned in paperwork. Whether you’re solo or growing into a team, the right digital setup scales. Add new clinicians, manage multiple locations, or integrate telehealth, while keeping notes, forms and medical records consistent and accessible.

FAQs

1. What is a therapy note?
   A concise record of what occurred in session, including interventions, the client’s response, and the plan for the next session.
2. How detailed should progress notes be?
   Enough to show medical necessity, reflect treatment goals, and document interventions without unnecessary personal details.
3. Are therapy notes the same as progress notes?
   Not exactly. Progress notes are formal summaries often shared for billing; therapy notes may include deeper reflections and analysis.
4. How long should therapists keep notes?
   Regulations vary by country and licensing board. Many professionals retain records for at least 5–7 years after the last session, or longer for minors.
5. Can clients request copies of their notes?
   In most jurisdictions, yes. Clients have the right to access records, except for private psychotherapy notes maintained solely for the therapist’s reference.
6. What’s the best format for counseling notes?
   SOAP and DAP are the most universal. Choose whichever structure best fits your workflow and agency requirements.