Free Therapy Note Templates
Copy-and-paste templates for SOAP, DAP, and BIRP notes with clinical prompts for each section. Use them as a starting point in any EHR.
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SOAP Note Template
S — Subjective
Client's self-reported experience
- ▸Chief complaint / presenting concern for this session:
- ▸Client's reported mood: [e.g., anxious, depressed, elevated, stable]
- ▸Sleep, appetite, energy changes since last session:
- ▸Significant events or stressors since last session:
- ▸Safety: Client [denies / endorses] suicidal ideation, homicidal ideation, and self-harm urges.
O — Objective
Therapist observations
- ▸Appearance: [grooming, eye contact, psychomotor activity]
- ▸Mood (observed): [e.g., dysphoric, euthymic, anxious, irritable]
- ▸Affect: [e.g., constricted, flat, full range, labile, appropriate]
- ▸Thought process: [e.g., linear, goal-directed, circumstantial, tangential]
- ▸Thought content: [e.g., no delusions, no SI/HI, safety concerns as above]
- ▸Insight: [good / fair / limited / poor] | Judgment: [intact / impaired]
A — Assessment
Clinical formulation
- ▸Diagnosis (DSM-5 name + ICD-10 code): e.g., Major Depressive Disorder, recurrent, moderate (F33.1)
- ▸Clinical formulation / themes this session:
- ▸Risk assessment summary: [low / moderate / high — rationale]
- ▸Progress toward treatment goals: [improving / stable / declining / insufficient data]
P — Plan
Next steps
- ▸Therapeutic interventions used this session (modality + specific technique):
- ▸Client homework / between-session tasks assigned:
- ▸Safety plan: [reviewed and unchanged / updated — see addendum]
- ▸Referrals or coordination: [none / psychiatry / crisis / other]
- ▸Next session: [date] at [time] — frequency: [weekly / biweekly / monthly]
- ▸Changes to treatment plan: [none / described below]
DAP Note Template
D — Data
Objective and subjective information
- ▸Client's presenting concern and mood report this session:
- ▸Significant events or themes explored:
- ▸Therapist observations (appearance, affect, cognition, safety screening):
- ▸Safety: Client [denies / endorses] SI/HI/self-harm.
A — Assessment
Clinical interpretation
- ▸Diagnosis (DSM-5 + ICD-10):
- ▸Clinical themes and patterns from this session:
- ▸Progress toward treatment goals: [improving / stable / declining]
- ▸Risk summary:
P — Plan
Treatment plan and next steps
- ▸Interventions used (modality + technique):
- ▸Between-session tasks assigned:
- ▸Next session and any referrals:
- ▸Treatment plan changes:
BIRP Note Template
B — Behavior
Client presentation and statements
- ▸Client presentation (timeliness, engagement, appearance):
- ▸Client statements and notable content:
- ▸Safety: Client [denies / endorses] SI/HI/self-harm.
I — Intervention
Therapeutic techniques used
- ▸Modality and specific techniques used:
- ▸Group activities or exercises (if applicable):
- ▸Psychoeducation topics covered:
R — Response
Client's response to interventions
- ▸Client's engagement and response during session:
- ▸Insights demonstrated or resistance noted:
- ▸Skill application and behavioral changes observed:
P — Plan
Next steps and follow-up
- ▸Homework or between-session practice:
- ▸Next session and frequency:
- ▸Referrals or treatment plan changes:
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