Client Note Template: How to Write Clear, Compliant, and Time-Saving Therapy Notes

For many mental health professionals, clinical care and documentation go hand in hand, but it's the note-taking that often feels overwhelming. After a demanding session, writing progress notes from scratch can drain your time and energy.

That’s where a client note template becomes invaluable. Using structured formats like SOAP, DAP, BIRP, or GIRP, therapists can document each session clearly, efficiently, and in accordance with legal and ethical standards.

This guide goes beyond the basics: we’ll break down each type of therapy note template, compare their use cases, provide real examples, and explore how you can automate notes using Supanote.

This blog will also help you understand how mental health progress notes fit into broader clinical workflows and compliance.

What Is a Client Note Template?

A client note template is a standardized format that helps therapists document each session’s key details. This includes the client’s presentation, client reports, clinical assessment, client response to interventions, and the treatment plan for future sessions.

Such templates are essential in clinical practice because they:

• Ensure consistency across notes
• Support medical necessity for insurance claims
• Make documentation shareable with other healthcare providers
• Help track progress over time
• Improve your overall documentation style
• Ensure compliance with legal and ethical standards

Using the right notes template also enhances your ability to write progress notes in a timely, organised, and professional manner.

Types of Therapy Notes

1. Progress Notes

These are the formal clinical records that go into a client's medical file. They capture:

• Session details: date, time, CPT code
• Client's behavior and symptoms
• Interventions used
• Clinical assessment and Mental status exam
• Risk assessment (if relevant)
• Updates to treatment plans

Progress notes are required in most healthcare settings and are often audited. Using a structured progress note template like SOAP or DAP helps ensure you meet all documentation standards.

2. Psychotherapy Notes

Also called private notes or process notes, these are for the therapist’s use only. They may contain:

• The therapist’s personal impressions
• Client’s emotional state or nuance
• Reflections on the therapeutic alliance

Psychotherapy notes are not part of the official medical record and are protected from disclosure under HIPAA. However, never mix them with progress notes.

Now, before diving into specific note templates like SOAP, DAP and BIRP, it's helpful to understand how these formats differ from general types of therapy notes like progress notes and psychotherapy notes.

Each template serves a unique purpose in supporting clinical documentation, compliance, and clarity.

Types of Progress Notes

1. SOAP Notes

SOAP is one of the most widely used progress note templates in clinical practice. It’s ideal for comprehensive, structured documentation and is frequently used in healthcare settings where medical necessity must be clearly demonstrated.

Structure:

• S (Subjective): Client's reported experiences and feelings
• O (Objective): Observable behavior and appearance
• A (Assessment): Clinical interpretation of symptoms
• P (Plan): Next steps or interventions

Example:

• S: Client reports feeling overwhelmed and having trouble focusing.
• O: Client appeared anxious, avoided eye contact, and had tense posture.
• A: Symptoms suggest continued difficulty managing anxiety and stress.
• P: Introduce relaxation techniques; reassess in next session.

2. DAP Notes

The DAP note template offers a more concise alternative to SOAP, commonly used in outpatient therapy and community mental health settings.

Structure:

• D (Data): Subjective and objective information
• A (Assessment): Therapist’s clinical impression
• P (Plan): Future interventions or next session goals

Example:

• D: Client presented with low energy and stated, "Nothing really excites me anymore."
• A: Depressive symptoms consistent with past mood episodes.
• P: Assign a coping skills journal and explore behavioral activation strategies.

3. BIRP Notes

BIRP notes are frequently used in behavioral therapy and residential care settings where behavioral tracking is essential.

Structure:

• B (Behavior): What the client did or said
• I (Intervention): What the therapist did in response
• R (Response): How the client responded
• P (Plan): Next steps

Example:

• B: Client appeared fatigued and disengaged.
• I: Facilitated guided breathing exercise and explored stressors.
• R: Client became more alert and participated in session activities.
• P: Continue skill-building and assess readiness for trauma work.

4. GIRP Notes

GIRP notes are best suited for goal-oriented therapy sessions, particularly when tracking progress toward specific treatment goals.

Structure:

• G (Goal): Client’s treatment objective
• I (Intervention): Techniques or tools used
• R (Response): Client’s engagement and behavior
• P (Plan): Follow-up steps or future goals

Example:

• G: Reduce anxiety during social interactions
• I: Roleplayed assertive communication
• R: Client reported increased confidence and less tension
• P: Practice technique outside of session and review next week

5. PIE Notes

PIE notes are commonly used in settings that emphasize intervention tracking and ongoing evaluation, such as intensive outpatient or inpatient programs.

Structure:

• P (Problem): Clinical issue observed
• I (Intervention): Therapist’s response or treatment
• E (Evaluation): Outcome of the intervention

Example:

• P: Client experiencing racing thoughts and irritability
• I: Provided psychoeducation on thought-challenging techniques
• E: Client stated the exercise was helpful and agreed to use it during the week

Which Therapy Note Format Should I Use

You might struggle to choose the right note format sometimes, especially with so many templates out there.

Here's a quick comparison of the most common therapy note templates and when to use them:

Pro Tip: Always match your note template to the clinical context. For example, use BIRP notes in residential programs and SOAP notes in individual outpatient care.

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What to Include in Every Therapy Note

A well-written therapy note strikes a balance between clinical accuracy and efficient communication. To make this process easier, we’ve broken down what to include into three clear categories:

1. Clinical Details

• Diagnosis and clinical assessment summary
• Client’s symptoms and mental status
• Interventions and techniques used (e.g., introduce relaxation techniques, journaling, CBT)
• Mental status exam (as clinically indicated)
• Risk assessment (suicidal ideation, harm to others, etc.)
• Updates to treatment plans and goals

2. Client Observations

• Client presentation and appearance (e.g., client appeared anxious, client appeared fatigued)
• Client’s emotional state and behavior
• Client reports and stated concerns
• Client response to interventions
• Notable changes from previous sessions

3. Administrative Info

• Session details: date, time, duration, CPT code
• Next session plan and follow-up tasks
• Justification of medical necessity

By using this checklist alongside a therapy note template such as SOAP, DAP, or BIRP, mental health professionals can ensure their documentation is clear, compliant, and clinically useful.

Here’s a universal checklist for therapy progress notes:

• Client presentation and appearance
• Session details: date, time, duration, CPT code
• Client’s symptoms and mental status
• Interventions and techniques used (e.g., introduce relaxation techniques, coping skills, thought records)
• Client response to interventions
• Risk assessment if applicable
• Updates to treatment plans and goals
• Next session plan
• Diagnosis and clinical assessment summary

Use a standardized format and digital notes tool like Supanote to speed up note taking while ensuring you don’t miss essential details.

Writing Notes Efficiently: Best Practices

1. Use a Notes Template
Start with a SOAP, DAP, or BIRP note template to reduce mental load.

2. Write Progress Notes Promptly
Capture details immediately after session while memory is fresh.

3. Use Digital Notes Tools
Practice management software and tools like Supanote help automate formatting and track progress.

4. Personalize, But Don’t Overwrite
Balance thoroughness with brevity. Don’t overexplain, but include critical details.

5. Review Legal Guidelines
Ensure your documentation meets legal and ethical standards—especially in healthcare settings.

Automating Therapy Notes with Supanote

Supanote is designed to simplify note taking for mental health professionals.

Here’s how it enhances documentation style and saves time:

• Voice-to-Note Conversion: Speak or type session summaries, and Supanote transforms them into compliant therapy note formats.
• Custom Templates: Choose from SOAP, DAP, BIRP, GIRP, or PIE notes. Supanote adapts to your documentation style.
• HIPAA Compliance: All notes are encrypted and secure- protecting client’s mental health data.
• Smart Suggestions: Supanote highlights missing fields like risk assessment, clinical assessment, and client response.
• Progress Tracking: Easily track client’s progress across sessions and modify future treatment plans with consistency.

Whether you work in solo practice or multidisciplinary teams, Supanote makes writing notes faster, clearer, and legally sound.

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Frequently Asked Questions

Q. What’s the difference between progress notes and psychotherapy notes?
A.Progress notes go in the medical record and are shared with insurance. Psychotherapy notes are for private reflection and never shared.

Q. What should I include in a progress note?
A. Session details, clinical assessment, client behavior, interventions used, client response, and a plan for the next session.

Q. Are psychotherapy notes required?
A. No, they’re optional. Many therapists use them to reflect on clinical hypotheses, transference, or the therapeutic alliance.

Q. How do I document suicidal ideation or risk of harm?
A. Always include a clear risk assessment, client’s mental status, any safety planning, and rationale for next steps.

Q. What’s the best template for brief check-ins?
A. Use a DAP or PIE note template to quickly document essential clinical content.

Q. How should I document if a client presents for mandated treatment?
A. Clearly indicate legal mandate, attendance, interventions, progress, and communication with referring entity.

Q. Should I always include a mental status exam?
A. Include it when clinically relevant or if symptoms, risk, or medication changes warrant a deeper status review.

Q. How do I track a client's progress over multiple sessions?
A. Use a consistent note format and reference previous sessions when relevant. Tools like Supanote help auto-link progress.

Q. Is it okay to use abbreviations in notes?
A. Only if they’re standard in your setting. Avoid jargon that might confuse reviewers or auditors.

Q. What’s the best way to write a note that includes trauma work?
A. Be clinical, not graphic. Document approach (e.g., EMDR, narrative exposure), client’s response, and plan for containment or follow-up.

Q. How often should I update treatment plans?
A. Every 90 days or as clinically indicated. Always document any change in goals or interventions.

Q. Can I include session quotes from a child client?
A. Yes, if developmentally appropriate and clinically relevant.

Q. What happens if I miss a detail like mental status or risk assessment?
A. It could affect insurance audits or clinical safety. Supanote highlights missing fields automatically.

Q. Are psychotherapy notes optional?
A. Yes. They're not required but useful for personal reflections.

Q. How do I handle writing notes for couples or groups?
A. Use a BIRP or GIRP note template to track each client’s behavior and response.

Q. What do I do if I forget to write notes for previous sessions?
A. Use a notes template to jog memory and document late, clearly marking date of entry.

Q. How should I document suicidal ideation or crisis sessions?
A. Include a clear risk assessment, mental status exam, client’s response, and safety planning.

Q. Can clients access their notes?
A. Yes. They can request progress notes, but not psychotherapy notes.

Q. Is it okay to copy parts of previous notes for consistency?
A. Yes, if updated and clinically relevant. Never copy-paste full notes.

Q. Should I include quotes from clients?
A. Yes, if they illustrate client’s symptoms, thinking patterns, or treatment engagement.

Q. How do I know if my documentation is audit-proof?
A. Follow a structured note format, include CPT codes, and use templates that match your setting.

Q. What’s a quick way to document after a short session?
A. Use a DAP note or PIE notes to capture the essential details.

Get Back to Clients, Not Paperwork

Supanote helps mental health professionals write clear, compliant therapy notes in minutes-using customizable templates like SOAP, DAP, and BIRP.

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