Counseling Session Note Templates and Examples
Updated: November 20, 2023Counseling notes, also commonly referred to as progress notes, are an integral part of the documentation process in therapy and counseling sessions. These notes serve as a record of the conversations, progress, and plans for clients seeking mental health support. They help counselors remember client details, create a timeline of therapy, and provide a foundation for the treatment plan.
This article delves into the nature of counseling notes, what they should include, and provides examples and templates to help guide professionals in creating effective documentation.
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What to Include in Counseling Notes
The content of counseling notes can vary depending on the method or template used, but generally, they should include:
- Client’s personal information
- Date, time, and duration of the session
- What was discussed during the session
- Any interventions or techniques used
- The client’s progress or any lack thereof
- Observations about the client’s mood, behavior, and affect
- Treatment plans or homework assignments
- Client’s response to the session
- Any potential risks or ethical concerns
Counseling Notes Templates
Several templates can be used to structure counseling notes effectively:
SOAP Notes Template
Patient Name: [Full Name]
Date of Service: [MM/DD/YYYY]
Session Number: [Number]
Therapist: [Full Name]
Subjective (S):
The subjective section is where you record the client’s statements and expressions of their personal experiences. This is the client’s narrative or report of their problems or progress.
– Client’s subjective description of their mood, feelings, and perceptions.
– Quotes or paraphrased statements from the client.
– Relevant personal stories or events shared by the client.
Objective (O):
The objective portion includes observable facts and the counselor’s observations during the session.
– Nonverbal behaviors observed (e.g., body language, tone of voice).
– Appearance and motor activity.
– Any assessments or scales used and their results.
– Direct observations rather than interpretations.
Assessment (A):
In the assessment, the counselor provides their professional judgment regarding the client’s situation, which may include diagnosis, progress, and any changes in condition.
– Diagnosis or diagnostic impressions.
– Progress towards goals.
– Changes in symptoms or behaviors.
– Risk assessment.
Plan (P):
This is the counselor’s plan for future sessions and may include homework for the client, any changes to treatment, and other recommendations.
– Next steps in treatment.
– Any homework or tasks assigned to the client.
– Changes to the treatment plan.
– When the next session will occur.
PAIP Notes Template
Patient Name: [Full Name]
Date of Service: [MM/DD/YYYY]
Session Number: [Number]
Therapist: [Full Name]
Problem (P):
Begin by identifying the primary problem or concern that was the focus of the session.
– Brief description of the problem.
– Why it’s currently a focus of treatment.
Assessment (A):
Assess the problem in the context of the session.
– Counselor’s assessment of the problem’s severity and impact.
– Any changes since the last session.
Intervention (I):
Describe any interventions used during the session to address the problem.
– Types of therapeutic interventions applied.
– Client’s participation in the intervention.
Plan (P):
Outline the next steps to address the problem.
– Any adjustments to the interventions.
– Goals for the next session.
– Follow-up or referrals needed.
DARP Notes Template
Patient Name: [Full Name]
Date of Service: [MM/DD/YYYY]
Session Number: [Number]
Therapist: [Full Name]
Data (D):
Record factual data about what happened in the session.
– Information about the client’s current situation.
– Factual occurrences in the session (e.g., “Client arrived 20 minutes late”).
Assessment (A):
Your professional interpretation of the data.
– Evaluation of the client’s issues and progress.
– Clinical impressions.
Response (R):
Your response to the assessment, including the treatment provided in the session.
– Intervention techniques used in response to the assessment.
– Your interaction with the client.
Plan (P):
Develop a plan based on the response to the treatment.
– Any changes to the treatment approach.
– Strategies for the client to try outside of sessions.
– Scheduling of future sessions or assessments.
BIRP Notes Template
Patient Name: [Full Name]
Date of Service: [MM/DD/YYYY]
Session Number: [Number]
Therapist: [Full Name]
Behavior (B):
Document specific behaviors of the client during the session.
– Observable behaviors, mood, and affect.
– Compliance with treatment or any challenges faced.
Intervention (I):
Detail the interventions used during the session.
– Specific therapeutic techniques or interventions implemented.
– Education or resources provided to the client.
Response (R):
Note the client’s response to the interventions.
– How the client reacted to the interventions.
– Any changes in behavior or mood during the session.
Plan (P):
Create a plan for ongoing or future therapy work.
– Treatment goals for the upcoming session(s).
– Homework for the client.
– Coordination with other professionals if needed.
By filling out these templates during or after each session, mental health professionals can maintain detailed and organized records that facilitate client care and support legal and ethical practice standards.
Examples of Counseling Notes
Here are simplified examples of what counseling notes might look like using different templates:
SOAP Notes Example:
Patient Name: Jane Doe
Date of Service: 11/14/2023
Session Number: 5
Therapist: Dr. Emma Parker
Subjective (S): “Jane expressed ‘feeling overwhelmed’ at work and noted an increase in anxiety, especially in social settings.”
Objective (O): Presented with fidgeting and restlessness. Discussed ongoing work stress. The GAD-7 anxiety scale score was 15.
Assessment (A): Symptoms suggest persistent anxiety, likely GAD. Some improvement in recognizing triggers but physical symptoms remain.
Plan (P): Introduce relaxation techniques next session. Jane to keep an anxiety trigger journal. Next appointment set for 11/21/2023.
PAIP Notes Example:
Patient Name: John Smith
Date of Service: 11/16/2023
Session Number: 3
Therapist: Dr. Michael Lee
Problem (P): “John reports chronic insomnia, exacerbated by work stress.”
Assessment (A): Insomnia remains a significant issue, with work stress as a likely contributing factor.
Intervention (I): Introduced CBT-I techniques, focusing on stimulus control and sleep hygiene education.
Plan (P): John to maintain a sleep diary. Review sleep diary and techniques effectiveness in the next session.
DARP Notes Example:
Patient Name: Emily Tran
Date of Service: 11/18/2023
Session Number: 8
Therapist: Dr. Susan Choi
Data (D): “Emily arrived on time, visibly upset over recent breakup and expressed feelings of isolation.”
Assessment (A): Depressive symptoms noted, consistent with an adjustment disorder with a depressed mood.
Response (R): Explored grief stages and provided validation. Initiated discussion on healthy coping mechanisms.
Plan (P): Emily to start a mood journal. Plan to delve deeper into grief processing in future sessions.
BIRP Notes Example:
Patient Name: Alex Johnson
Date of Service: 11/20/2023
Session Number: 6
Therapist: Dr. Rachel Green
Behavior (B): “Alex displayed initial withdrawal but became more engaged after trust-building exercises.”
Intervention (I): Utilized motivational interviewing. Conducted a role-play for assertive communication within the family context.
Response (R): Alex showed a gradual increase in openness and was receptive to role-play, finding it ‘helpful.’
Plan (P): Alex agreed to apply communication techniques with his family. To further explore family dynamics in the next session.
Group Notes vs Individual Notes
Group counseling notes differ from individual notes as they must capture the dynamics and interactions within the group setting. These notes should still include the date, time, and duration of the session, but also the group’s themes, processes, participation levels of individual members, and any interventions used by the counselor.
Examples of Counseling Group Notes
Here are counseling group note examples that reflect the involvement of a group setting:
SOAP Notes Example for Group Counseling:
Group Name: Workplace Stress Management Group
Date of Service: 11/14/2023
Session Number: 5
Group Facilitator: Dr. Emma Parker
Members Present: Jane Doe, among others
Subjective (S): Jane shared in the group setting that she has been ‘feeling overwhelmed’ at work and has experienced an increase in anxiety, particularly in social situations within the workplace.
Objective (O): Within the group, Jane was observed fidgeting and showing signs of restlessness. She actively participated in group discussions about ongoing work-related stress. Jane’s self-reported GAD-7 anxiety scale score was 15.
Assessment (A): Within the group dynamic, Jane’s symptoms suggest persistent anxiety, likely Generalized Anxiety Disorder (GAD). She is making progress in recognizing her triggers when reflected in the group’s feedback, but physical symptoms are still evident.
Plan (P): Plan to introduce relaxation techniques in the next group session. Encourage Jane and other group members to maintain an anxiety trigger journal. The next group session is set for 11/21/2023.
PAIP Notes Example for Group Counseling:
Group Name: Sleep Wellness and Management Group
Date of Service: 11/16/2023
Session Number: 3
Group Facilitator: Dr. Michael Lee
Members Present: John Smith, among others
Problem (P): John voiced to the group his struggle with chronic insomnia, which is exacerbated by stress from his job.
Assessment (A): The group explored that John’s insomnia is a significant concern, with occupational stress being a probable contributing factor, a common theme among group members.
Intervention (I): The group was introduced to Cognitive Behavioral Therapy for Insomnia (CBT-I) techniques, with a focus on stimulus control and sleep hygiene, which John and others practiced during the session.
Plan (P): John, along with group members, is to maintain a sleep diary. The effectiveness of the techniques and the sleep diary will be reviewed in the next group session.
Counseling notes are an essential tool in the mental health field, providing a written account of therapeutic encounters that are crucial for effective treatment planning and continuity of care. By using structured templates like SOAP, PAIP, DARP, or BIRP, mental health professionals can ensure that they are capturing the necessary information to support their clients’ journeys.
Whether documenting individual or group sessions, these notes serve as a professional record that enhances the therapeutic process, supports clinical decision-making, and ensures legal and ethical standards are maintained. With practice and the right template, writing comprehensive and helpful counseling notes can become a natural and integral part of the therapeutic practice.
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