A therapy note records what happened in a session and why it matters clinically. That includes the presenting concern, what a clinician observed, the intervention used, how the client responded, and the plan for what comes next. Most practices write it in SOAP, DAP, or BIRP. The template below works as a starting point regardless of which format a practice lands on.
Choosing a Format: SOAP, DAP, or BIRP
| Format | Fits best when |
|---|---|
| SOAP | The session includes real exam or measurement content, common in psychiatric medication management |
| DAP | Work is stable and ongoing, and a faster note is still clinically useful |
| BIRP | A practice bills insurance and needs the intervention and the client's response documented separately |
For the full comparison, including how the same session reads in each format, see DAP vs BIRP vs SOAP.
Blank Therapy Note Template
A general structure that works before a practice has settled on SOAP, DAP, or BIRP. Copy it into a notes app or an EHR, or download and print it.
Download blank template (PDF)Free, no signup required.
Example of a Completed Therapy Note
A weekly individual session addressing work-related stress. This is illustrative. It does not describe a real client and contains no protected health information.
- Presenting concern. Client reports ongoing stress tied to an upcoming performance review, with two nights of disrupted sleep this week.
- Mental status and observations. Alert and engaged, with a mildly anxious affect that eased over the course of the session.
- Intervention used. Cognitive reframing applied to catastrophic predictions about the review. Practiced a brief grounding exercise.
- Client response. Client identified two specific worst-case thoughts and generated a more balanced alternative for one of them unprompted.
- Plan for next session. Practice the reframing technique on the second thought before the review, and follow up on how the review went.
