12 Effective Therapy Note Templates with Examples

Therapy notes serve as the official record of each client session. They document treatment progress, support insurance reimbursement claims, and protect therapists legally.

• Legal Protection: Comprehensive notes provide evidence of appropriate care if questions arise about treatment decisions.
• Insurance Compliance: Proper documentation supports medical necessity and ensures timely reimbursement from payers.
• Treatment Continuity: Detailed session records help other clinicians understand the client’s history and current treatment plan.
• Progress Tracking: Consistent note formats make it easier to measure client outcomes over time.

Writing effective therapy notes requires balancing thoroughness with efficiency. The following practices help therapists create documentation that meets clinical and compliance standards.

Write notes immediately after sessions

Complete documentation within 24 hours while details remain fresh. Waiting longer leads to incomplete or inaccurate records.

Use consistent formatting

Choose a note format such as SOAP, DAP, or BIRP and apply it consistently across all clients. Standardized structures speed up writing and make records easier to review.

Focus on observable behaviors

Document what you directly observed during the session rather than interpretations. Use specific language: “Client reported sleeping 3 hours per night” rather than “Client seemed tired.”

Include treatment plan progress

Each note should reference the client’s treatment goals and document movement toward those objectives.

Templates transform therapy documentation from a time-consuming burden into a streamlined process. Therapists who use standardized templates report significant improvements in both efficiency and note quality. Using templates reduces documentation time by providing a consistent structure for every session. Templates also ensure compliance with insurance and regulatory requirements by prompting therapists to include specific elements that payers expect to see. TextExpander Snippets allow therapists to insert complete note templates with a few keystrokes, cutting documentation time while maintaining quality standards.

SOAP notes organize session information into four categories: Subjective, Objective, Assessment, and Plan. This format is widely accepted across healthcare settings and works well for therapy documentation.

Subjective

Record the client’s self-reported symptoms, concerns, and experiences. Include direct quotes when relevant.

Objective

Document observable data including appearance, behavior, affect, and speech patterns.

Assessment

Provide your clinical interpretation of the subjective and objective findings.

Plan

Outline the next steps for treatment including interventions, homework, and next appointment.

DAP notes condense therapy documentation into three sections: Data, Assessment, and Plan. This format works well for therapists who prefer a shorter structure while still capturing essential session information.

BIRP notes structure documentation around Behavior, Intervention, Response, and Plan. This format emphasizes the therapeutic work done during each session and the client’s reaction to treatment.

Progress notes provide a flexible format for documenting therapy sessions without strict structural requirements. These notes focus on capturing treatment progress, session content, and planning for future care.