Understanding the Distinction: Progress Notes vs. Psychotherapy Notes
Before examining specific templates, mental health professionals must understand the legal distinction between these two documentation types. Progress notes form part of the official medical record, accessible to insurance companies and other authorized parties. Psychotherapy notes, however, receive special protection under HIPAA, containing the therapist's personal observations and analysis, kept separate from the primary record.
Before diving into templates, note that progress notes are part of the official record, accessible to authorized parties, while psychotherapy notes enjoy extra HIPAA protection and are kept separately.
Why Effective Therapy Note Documentation Matters in 2025
Modern therapist notes serve multiple critical functions:
- Legal Protection: Creates defensible documentation for potential audits or litigation
- Clinical Continuity: Ensures seamless care transitions between providers
- Treatment Tracking: Monitors client progress against established goals
- Reimbursement Justification: Supports insurance claims with necessary detail
- Professional Communication: Facilitates collaboration with interdisciplinary teams
11 Professional Therapy Note Templates with Clinical Examples
1. SOAP Notes Template
The gold standard progress note template, SOAP, provides comprehensive session documentation.
Structure:
- S (Subjective): Client's reported experiences and concerns
- O (Objective): Observable behaviors and clinical data
- A (Assessment): Professional interpretation and analysis
- P (Plan): Treatment direction and interventions
Example:
- S: "Client reports persistent insomnia lasting three weeks, stating 'I lie awake replaying conversations from work.'"
- O: Client displayed visible fatigue, yawning frequently. Maintained appropriate eye contact. PHQ-9 score: 12 (moderate depression).
- A: Insomnia appears linked to workplace anxiety. Rumination pattern is evident. No safety concerns identified.
- P: Introduce sleep hygiene protocol. Begin CBT-I techniques next session. Monitor for medication evaluation if symptoms persist.
2. DAP Progress Notes Template
This streamlined format combines subjective and objective data into one section.
Structure:
- D (Data): Combined subjective reports and objective observations
- A (Assessment): Clinical interpretation
- P (Plan): Future interventions
Example:
- D: Client presented with flat affect, reporting "nothing brings joy anymore." Declined participation in previously enjoyed activities. Hygiene appears neglected.
- A: Anhedonia and self-care deficits suggest worsening depressive symptoms. Risk assessment completed—no immediate concerns.
- P: Implement behavioral activation schedule. Coordinate with the psychiatrist for medication review.
3. BIRP Therapy Notes Template
Behavior-focused documentation is ideal for evidence-based interventions.
Structure:
- B (Behavior): Presenting concerns and actions
- I (Intervention): Therapeutic techniques employed
- R (Response): Client's reaction to interventions
- P (Plan): Next steps
Example:
- B: Client exhibited panic symptoms when discussing the upcoming flight.
- I: Guided progressive muscle relaxation. Practiced diaphragmatic breathing.
- R: Client reported anxiety reduction from 8/10 to 4/10. Successfully completed full relaxation sequence.
- P: Assign daily breathing exercises. Schedule exposure hierarchy development.
4. GIRP Therapy Note Format
Goal-oriented documentation linking sessions to treatment objectives.
Structure:
- G (Goal): Specific treatment plan goal addressed
- I (Intervention): Methods used
- R (Response): Progress observed
- P (Plan): Continued approach
Example:
- G: Improve assertive communication skills (Goal #3)
- I: Role-played boundary-setting scenarios with family members
- R: Client successfully used "I" statements in three practice scenarios
- P: Apply learned skills with sister this week; process results next session
5. PIE Progress Notes Examples
Problem-focused documentation is common in medical settings.
Structure:
- P (Problem): Primary concern
- I (Intervention): Clinical actions
- E (Evaluation): Outcome assessment
Example:
- P: Grief following spouse's death six months ago
- I: Facilitated narrative therapy techniques to process loss
- E: Client expressed relief at sharing memories; tears present but manageable
6. PAIP Therapy Notes Examples
Comprehensive assessment-driven format.
Structure:
- P (Problem): Presenting issue
- A (Assessment): Clinical evaluation
- I (Intervention): Treatment provided
- P (Plan): Forward direction
Example:
- P: Adolescent oppositional behavior at home
- A: Behavior appears attention-seeking; family dynamics contributing
- I: Family systems intervention; communication skills training
- P: Schedule family session; individual work on emotional regulation
7. Group Therapy Notes Template
Components:
- Group Theme & Size: Specify the session’s focus and the number of participants.
- Group Process: Summarize the overall dynamics and interactions.
- Individual Contributions: Highlight key member insights and participation.
- Interventions: List the therapeutic techniques employed.
- Next Steps: Outline plans for the following session.
Example:
Anxiety management group (6 members). Focus: Cognitive distortions. Group cohesion is strong—member J.K. shared a breakthrough in recognizing catastrophic thinking. Practiced thought-stopping techniques. Next session: Introduce mindfulness strategies.
8. Couples Therapy Notes Template
Overview:
- Focus on the relational dynamics between partners.
- Detail specific interventions aimed at improving communication and resolving conflicts.
Example:
Partners demonstrated improved communication using the speaker-listener technique and addressed recurring conflicts over household responsibilities. Both were committed to weekly check-ins, and the Gottman emotional bank account exercise was assigned.
9. Narrative Therapy Notes Template
Approach:
- Story Exploration: Document the client’s narrative to uncover underlying issues.
- Externalization: Distinguish the problem from the client’s identity.
- Insight & Reflection: Capture the insights gained during the session.
- Homework: Assign reflective exercises such as journaling.
Example:
Session focused on exploring the client's relationship with perfectionism. The client identified a pattern originating from childhood academic pressures. We externalized 'The Perfectionist Voice' to examine its impact on current work stress. The client connected this pattern with recent anxiety symptoms. Homework: Journal instances when perfectionism emerges.
10. CBT Progress Note Template
Structure:
- Identified Automatic Thoughts: Highlight the recurrent negative beliefs.
- Cognitive Distortions: Note patterns like all-or-nothing thinking.
- Behavioral Experiments: Record any experiments or interventions conducted.
- Homework & Skill Application: Track compliance and emerging strategies for change.
Example:
Explored the client's thought, 'I'm worthless at work.' Recognized all-or-nothing thinking and developed a balanced thought: 'I make mistakes, but I contribute value.' Assigned a thought record exercise to further apply this skill.
Best Practices for Professional Therapy Note Documentation
Maintain Objectivity
Document observable behaviors rather than interpretations. Write "client clenched fists" instead of "client was angry."
Ensure Timeliness
Complete therapist notes within 24-48 hours while details remain fresh. Many insurance carriers require timely documentation.
Balance Detail with Brevity
Include essential information without excessive detail. Focus on clinically relevant data that supports treatment decisions.
Protect Confidentiality
Use initials or identification numbers. Store all therapy notes examples in HIPAA-compliant systems with appropriate encryption.
Link to Treatment Goals
Every therapy note should demonstrate a connection to established treatment plan objectives, showing measurable progress.
Conclusion
Selecting the appropriate progress note template enhances clinical practice efficiency while ensuring comprehensive documentation. Whether utilizing traditional SOAP notes or specialised formats, consistency and attention to detail remain paramount. As mental health professionals adapt to evolving documentation requirements in 2025, these templates provide the foundation for ethical, effective practice management. The key lies not in the format chosen, but in the commitment to accurate, timely documentation that serves both client care and professional standards.
Frequently Asked Questions
Q1. How to write counselling notes example?
Start with basic session details (date, time, duration), then document using a structured format like SOAP or DAP. Include the client's reported concerns, your observations, clinical assessment, and planned interventions. For example: "Client reported feeling 'overwhelmed by work deadlines.' Appeared anxious, fidgeting throughout the session. Discussed time management strategies and assigned priority-setting exercise for next week."
Q2. How do therapists write notes?
Therapists typically write notes immediately after sessions using standardised templates like SOAP, BIRP, or DAP formats. They focus on documenting observable behaviors, client statements, interventions used, and treatment progress. Most therapists now use electronic health records (EHRs) or practice management software to streamline documentation while maintaining HIPAA compliance.
Q3. What is the best format for psychotherapy notes?
The SOAP format remains the gold standard for most clinical settings due to its comprehensive structure and wide acceptance by insurance providers. However, the "best" format depends on your practice setting, theoretical orientation, and documentation requirements. Many therapists prefer DAP notes for their efficiency or GIRP notes for goal-focused treatment tracking.
Q4. Does TherapyNotes have templates?
Yes, TherapyNotes software includes built-in templates for various note formats including SOAP, DAP, BIRP, and GIRP. The platform offers customizable templates that auto-populate client information and allow therapists to create their own formats. These templates help ensure consistent documentation and save time during the note-writing process.
Q5. What should not be included in therapy notes?
Avoid including personal opinions, judgmental language, or unnecessary details about third parties. Never document information that could be harmful if disclosed, such as speculative diagnoses or countertransference reactions. Keep psychotherapy notes (your personal process notes) separate from official progress notes that may be shared with insurance or other providers.
Q6. How long should a therapy note be?
A well-written therapy note typically ranges from 150-300 words, taking 5-10 minutes to complete. The note should be comprehensive enough to justify services and track progress, yet concise enough to be practical. Quality matters more than quantity; focus on including clinically relevant information rather than lengthy narratives.
Q7. Are handwritten therapy notes still acceptable?
While handwritten notes remain legally acceptable, most practices have transitioned to electronic documentation for efficiency and legibility. If using handwritten therapist notes, ensure they're legible, dated, signed, and stored securely. Many regulatory bodies and insurance companies now prefer typed notes for clarity and easier record sharing.
Q8. How often should progress notes be updated?
Progress notes must be completed for every client contact, including sessions, phone calls exceeding 10 minutes, and crisis interventions. Document immediately after the session or within 24-48 hours maximum. Some insurance contracts specifically require documentation within certain timeframes, so check your payer agreements for specific requirements.
Q9. What's the difference between progress notes and treatment plans?
Progress notes document individual session content and track ongoing therapeutic work, while treatment plans outline overall goals, objectives, and intervention strategies. Progress notes examples show moment-to-moment therapeutic process, whereas treatment plans provide the roadmap for the entire course of therapy. Both documents should align and reference each other for continuity of care.