Therapy Notes Template with Examples

LJ Acallar

March 4, 2025•20 min read

Fact checked by Dr. Ben Condon

Template

Therapy Note Template

This therapy note template was designed by a psychiatrist to capture all essential details and prescribed medications during initial sessions. It aims to help with the accurate documentation of client history, concerns, and initial assessments while ensuring professional and legal compliance. With this template, you can efficiently:

Record critical details via pre-filled fields such as history, chief complaint, HPI and interventions used, reducing manual entry and aligning with HIPAA and GDPR standards
Auto-identify billing and diagnostic codes, eliminating the need to manually search for them
Leverage advanced voice-to-text capabilities to document sessions effortlessly as you speak, so you can focus entirely on the conversation while Heidi, your free AI medical scribe, captures key details in real-time‍‍

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What is a Therapy Notes Template?

A therapy notes template is a written record with a structured format used by mental health professionals, including therapists, counselors, and social workers, to document client meetings, track progress, and plan treatment.

Therapy notes, or counseling notes, are not just paperwork; they are essential for providing quality care and making clients feel truly heard. Writing them from scratch every time can be exhausting and take your focus away from building a sincere relationship with your client.

In this article, we’ll briefly discuss the difference between therapy notes and progress notes, the benefits of having a good template, how to write a therapy note with examples in common formats, and featured therapy note templates to help you save crucial time and still capture every important detail of your conversations.

Therapy Notes vs. Progress Notes

While often used interchangeably, therapy notes and progress notes serve different purposes in mental health documentation.

Therapy notes are a broader term that can include progress notes but also psychotherapy notes, which are a therapist’s private reflections, insights, and hypotheses. Unlike progress notes, therapy notes are legally protected and kept separate from clinical records.

Progress notes are part of a client’s official record and summarize key details from each appointment, including symptoms, interventions, and treatment progress. They ensure continuity of care and may be shared with other providers or insurance companies.

Top Challenges of Traditional Note-Taking for Therapy Notes

Therapists, psychologists, and other mental health professionals often struggle with the demands of documenting therapy notes while managing a full caseload. Here are just five of the most common concerns raised by those who have been manually writing therapy notes:

1. Risk of Manual Errors

Relying on handwritten or manually typed notes increases the risk of missing key details, misinterpreting information, or struggling with illegible handwriting. Over time, these errors can impact the quality of care and make it difficult to track client progress accurately.

2. Time Constraints

Therapists often see multiple clients in a day, leaving little time between appointments to write detailed notes. Some prefer to revisit their therapy notes later on when all the clients for the day are finished, but at this point, documentation has already piled up, leading to extended time spent at the clinic catching up on documentation, which can lead to long-term burnout.

3. Inconsistent Records

Different therapy approaches require different documentation styles, making it difficult to maintain uniform records. Various note-taking methods from session to session can lead to inconsistencies that may complicate treatment planning and case reviews.

4. Balancing Detail and Efficiency

Therapists need to strike a balance between capturing essential insights and maintaining efficiency. Writing overly detailed notes can consume valuable time, while overly brief notes may lack the necessary context and depth of information making them less useful for future reference or compliance requirements.

5. Legal and Ethical Concerns

Mental health professionals must ensure therapy or counseling notes remain compliant with legal and ethical standards. In the United States, therapy notes must adhere to Health Insurance Portability and Accountability Act (HIPAA) regulations, ensuring client confidentiality and secure storage of medical records.

For European Union (EU) member states and European Economic Area (EEA) countries, similar protections exist under General Data Protection Regulation (GDPR) and local healthcare laws. The UK has its own UK GDPR, but with its own specifications.

Another concern in therapy documentation is confidentiality versus necessary disclosure. For example, if a client expresses intent to harm themselves or others, the therapist must carefully document the situation while ensuring compliance with mandatory reporting laws.

Proper documentation, including clinical assessment and rationale for a risk assessment, enhances patient care and protects the therapist from legal repercussions.

How an Effective Therapy Notes Template Can Help

Therapy note templates can help address these challenges and allow you to focus on who matters the most: the person sitting in front of you. A good therapy notes template, especially when powered by AI like Heidi, streamlines documentation and improves care by:

Saving Time and Improving Accuracy - Captures details accurately, reducing the risk of missing critical information based on your conversations
Enhancing Progress Monitoring - Serves as a valuable reference for easily tracking your client’s progress and adjusting treatment accordingly
Complying with Legal and Ethical Standards - Provides a clear framework for documenting meetings securely, adhering to global and local regulations
Reducing Administrative Burden - Integrates AI and automation to ease your mental load and decrease therapy documentation time by at least 50%

For example, Psychiatrist Dr. Tony Fernando used to spend an average of 3 hours per day writing notes. With Heidi, he instantly slashed that to just 30 to 60 minutes.

As Dr. Fernando noted, “Heidi is very good when it comes to follow-up appointments. When I see a patient for follow-up—Heidi does her thing. I click ‘generate’ and the notes and plan are done. I just add my bit in terms of Mental Status Exam and diagnosis.”

What are the Different Therapy Note Template Formats?

Therapy notes come in different formats, each serving a unique purpose depending on the therapist’s documentation style and specialty. The most commonly used formats include SOAP, DAP, and BIRP notes, all of which provide a structured way to capture essential details while ensuring consistency and compliance.

Therapy Note Format 1: SOAP

SOAP note templates follow a structured approach widely used in various healthcare settings. Each section serves a specific purpose:

S (Subjective): The client’s self-reported symptoms, concerns, and reasons for the visit.
O (Objective): The therapist’s observations, including the client’s demeanor, speech, and body language.
A (Assessment): The therapist’s clinical interpretation, diagnosis, or progress evaluation.
P (Plan): The next steps in treatment, such as interventions, assignments, or follow-ups.

If a client reports increased anxiety, the therapist would document their statements in the subjective section, note their fidgeting or tense body language in the objective section, assess their anxiety progression, and plan interventions like mindfulness exercises.

Therapy Note Format 2: DAP

DAP note templates offer an alternative format with a stronger focus on assessment and planning. It consists of:

D (Data): A combination of the client’s subjective experiences and the therapist’s objective observations.
A (Assessment): The therapist’s clinical interpretation, noting progress or setbacks.
P (Plan): The proposed treatment approach, including therapy techniques, referrals, or follow-ups.

A therapist working with a client experiencing depressive symptoms might document reported feelings of low energy and hopelessness under data, analyze progress toward CBT interventions in assessment, and plan to introduce additional coping mechanisms in the next meeting.

Therapy Note Format 3: BIRP

BIRP note templates are structured to emphasize behavioral interventions, making them particularly useful in behavioral therapy settings:

B (Behavior): The client’s actions, statements, and observable mood.
I (Intervention): Techniques or interventions applied by the therapist.
R (Response): The client’s reaction to the intervention.
P (Plan): Adjustments for future conversations based on the client’s response.

If a therapist employs exposure therapy for a client with phobias, they may document avoidance behaviors under behavior, record the intervention used (e.g., gradual exposure techniques), note client distress levels in response, and outline a plan to increase exposure intensity in subsequent appointments.

How to Write Therapy Notes Effectively

Writing effective therapy notes requires a structured and concise approach to ensure clarity, accuracy, and compliance with professional and legal standards. Here are 6 simple steps to writing effective therapy notes:

1. Start with Basic Information

Every therapy note should begin with fundamental details, including:

Session date – Helps maintain a chronological record.
Client’s name – Ensures proper identification.
Therapist’s credentials – Demonstrate the provider's qualifications and role.

Including this information upfront keeps records organized and compliant with legal and professional standards.

2. Use a Structured Format

Using a standardized format keeps therapy notes clear, consistent, and comprehensive. As earlier mentioned, the most common formats include SOAP, DAP, and BIRP. Choosing a structured format ensures that all critical aspects of the appointment are documented efficiently.

3. Document Key Observations

Capturing client behavior, mood, and key statements helps build a clear picture of their emotional state and therapeutic progress. This might include:

Nonverbal cues (e.g., fidgeting, avoiding eye contact, or relaxed posture).
Emotional expressions (e.g., “The client appeared anxious and reported feeling overwhelmed at work”).
Significant quotes from the client that provide insight into their thought patterns or concerns.

Observations should be objective and factual, avoiding assumptions or personal opinions.

4. Describe Interventions Used

Clearly record the therapeutic techniques and approaches applied during the meeting. Examples include:

Cognitive Behavioral Therapy (CBT) techniques, such as reframing negative thoughts.
Relaxation exercises, like guided breathing or mindfulness.
Role-playing to practice social skills or conflict resolution.

5. Evaluate Client Progress

Assess the client’s response to interventions and any progress made since previous conversations. Consider:

Changes in symptoms or behavior (e.g., "The client reported fewer panic attacks this week").
Client engagement (e.g., "Actively participated in exercises and demonstrated improved self-awareness").
Challenges or setbacks (e.g., "Continued struggles with insomnia despite practicing relaxation techniques").

6. Plan for Future Conversations

End each note with a clear plan for a follow-up, ensuring continuity and direction. This might include:

Future meeting goals (e.g., "Next meeting will focus on emotion regulation techniques").
Homework assignments (e.g., "Client will journal thoughts before bed to track anxiety triggers").
Referrals or additional support (e.g., "Referred to a psychiatrist for medication evaluation").

Having a structured plan keeps therapy focused and helps clients stay engaged in their treatment journey.

Therapy Notes Template Example

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Therapy Notes Examples

Client Name: Jane Doe
Date: January 25, 2025
Therapist: Dr. Gary Smith, LMFT

SOAP Therapy Notes:

S (Subjective): Jane reported experiencing increased anxiety over the past week due to work stress. She mentioned difficulty sleeping and recurring thoughts of self-doubt.
O (Objective): Client appeared fatigued, with tense posture and fidgeting hands. Speech was slightly rushed but coherent.
A (Assessment): Jane’s anxiety levels remain high, but she is showing increased awareness of her stress triggers. She engaged well in the grounding exercises introduced in the previous conversation.
P (Plan): Continue with mindfulness exercises and introduce cognitive restructuring techniques. Assign breathing exercises for daily practice and reassess progress in the next appointment.

DAP Therapy Notes:

D (Data): Jane discussed her ongoing difficulties managing work-related stress. She reported feeling overwhelmed with deadlines and struggling with concentration at work. Additionally, she mentioned experiencing heart palpitations during moments of high stress.
A (Assessment): Jane is exhibiting signs of work-related anxiety, and her physical symptoms suggest heightened physiological responses to stress. She has made some progress in recognizing stress triggers but continues to struggle with emotional regulation.
P (Plan): Introduce relaxation techniques, including progressive muscle relaxation and guided imagery. Encourage Jane to log stress levels daily and practice deep breathing exercises between appointments. Monitor changes in symptoms in the next follow-up.

BIRP Therapy Notes Example

B (Behavior): Jane presented with nervous energy, frequently shifting in her chair and avoiding eye contact when discussing work stress. She described her stress levels as an “8 out of 10” and acknowledged feeling emotionally drained.
I (Intervention): Therapist guided Jane through a short deep-breathing exercise and explored cognitive reframing techniques to manage overwhelming thoughts.
R (Response): Jane responded positively to the breathing exercise, reporting a slight decrease in tension. She demonstrated understanding of cognitive reframing but expressed doubt about implementing it independently.
P (Plan): Assign cognitive reframing exercises as homework, with a focus on identifying and restructuring negative thoughts. Reassess progress in the next meeting and introduce additional stress-management strategies if needed.

Therapy note templates ensure consistency and efficiency in your documentation. Now, what if we take that level of efficiency much higher? Integrating your structured templates with AI-driven automation is the most powerful combination that accelerates your workflow efficiency and enable deeper client engagement.

Therapy Notes Made Easier with Heidi

With Heidi, the AI medical scribe for all clinicians, you can instantly generate personalized therapy notes in any format. By reducing administrative strain, Heidi not only frees up more time for client care but also improves compliance by minimizing the risk of errors. Here’s how it works:

Transcribe – After confirming patient consent, press start at the beginning of your session, and Heidi captures every word in real-time, transforming your conversation into structured therapy notes.
Organize for Compliance – Pick your preferred format (SOAP, DAP, or BIRP), and Heidi automatically structures your notes while ensuring HIPAA and GDPR compliance.
Automate Billing & Diagnoses – Need more? Ask Heidi to suggest billing and diagnostic codes instantly, making reimbursement easier and reducing errors.

Heidi is compliant around the world, meeting the highest security and privacy standards for clinical documentation. Over 100,000 healthcare professionals worldwide trust Heidi to streamline their workflow, allowing them to spend less time on paperwork and more time delivering quality care.

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Free Therapy Notes Templates

Psychotherapy Notes Template

This psychotherapy notes template helps therapists track client conversations with sections for observations, assessments, and future plans. It's ideal for following progress and setting goals while keeping detailed records of meetings and treatment plans.

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Counseling Notes Template

This counseling notes template helps counselors easily document meetings, focusing on key issues, obstacles, and progress. It includes sections for the next steps and scheduling, making it a useful tool for improving therapy and client results.

View Template

Initial Therapy Note Template

This initial therapy session note template is for psychologists to use during a client's first visit, capturing key details like presentation, concerns, and history. It aids in planning treatment and, with AI support, makes documentation easier so therapists can focus on care.

View Template

FAQs about Therapy Note Templates

How can I create my own therapy note templates?

To create your own therapy note templates, start by selecting a structured format and identifying key sections such as client information, appointment details, interventions, progress, and future plans, among others. An AI medical scribe like Heidi can help by automatically formatting your notes from recorded conversations.‍

What is the best format for therapy note templates?

The best format for therapy note templates depends on your clinical needs and documentation style. For example, a psychiatrist may opt for structured, medical-style documentation, while a social worker may prefer a more simplified approach focusing on observations and clinical interpretation. For improved efficiency, Heidi can auto-structure notes in any format you prefer. Watch how.

Can therapy notes be used in court?

Therapy notes can be used in court, but their admissibility depends on the type. Progress notes, which document treatment details, may be subpoenaed, while psychotherapy notes (as legally called) are protected under HIPAA and typically require client consent. Always consult legal counsel before disclosing records to ensure ethical and legal compliance.

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