Therapists use 7 main types of progress notes: SOAP, DAP, BIRP, GIRP, PIE, DARP, and APSO. Each format documents therapy sessions differently, and picking the wrong one for your setting creates compliance gaps, slows documentation, and complicates billing.
This guide covers all 7 formats with definitions, real examples, and best practices. You will also find a breakdown of mental health progress notes versus psychotherapy notes, a distinction that creates problems for a lot of clinicians.
What Are Progress Notes in Therapy?
Progress notes are official clinical records that document what happened during a therapy session. They include the client’s presentation, the therapist’s observations, clinical impressions, and the plan for next steps.
Therapists, psychologists, licensed counselors, social workers, and psychiatrists all use them across every clinical setting: private practice, community mental health centers, inpatient units, and telehealth.
Progress notes are not optional. They are a legal requirement for licensed mental health professionals and a permanent part of the client’s medical record.
Why Progress Notes Matter in Mental Health Documentation
Progress notes protect your license, support billing, and keep care consistent.
Here is what they specifically do:
- Legal protection: If a client’s care is ever disputed or reviewed, your notes are the documented record of what you did and why.
- Insurance reimbursement: Miss a required field, and the claim comes back denied. Insurers will not pay without documentation that meets their standards.
- Treatment continuity: Another provider should be able to pick up right where you left off. That only works if your notes are clear and current.
- Clinical communication: Your notes are how the rest of the team stays informed. Psychiatrists, case managers, and supervisors all rely on what you write.
- Audit readiness: Records can be requested without warning. Solid notes mean you are never caught off guard.
- Risk management: When safety concerns come up, your notes are proof that you addressed them. That matters legally and clinically.
What Should Be Included in a Progress Note?
Every therapy progress note should cover these:
- Client name, date of birth, session date
- What the client reported: mood, concerns, symptoms
- What you observed: appearance, affect, behavior
- Your clinical read: progress, diagnostic impressions
- The plan: next steps, homework, referrals
- What approach did you use: CBT, DBT, EMDR, etc.
- Risk assessment, even if nothing came up
- Your signature, credentials, and ate
Progress Notes vs Psychotherapy Notes
Progress notes and psychotherapy notes are not the same thing. One goes in the official record. The other stays private. Mixing them up puts you at risk under HIPAA.
| Feature | Progress Notes | Psychotherapy Notes |
| Purpose | Official clinical documentation | Private therapist reflections |
| HIPAA Status | Part of the official medical record | Separately protected, stricter access rules |
| Who Can Access | Insurers, supervisors, treatment team | Usually, only the treating therapist |
| Content | Standardized clinical format | Personal impressions, hypotheses, reactions |
| Required? | Yes, for licensed practice | No, kept at therapist’s discretion |
The 7 Types of Progress Notes Used by Therapists
No single format works for every clinical setting. The type of therapy notes you use should match your environment, billing requirements, and caseload.
Here are all 7 types of progress notes used in mental health practice.
SOAP Notes
SOAP notes are a type of progress notes that use a four-part structure that works in any setting where multiple providers read the same clinical record. They are the most widely recognized documentation format in both healthcare and therapy.
SOAP stands for Subjective, Objective, Assessment, and Plan. The format comes from medicine, which is why it stays common in integrated health settings, hospital-based programs, and multidisciplinary teams.
SOAP Note Format Explained
Subjective (S): What the client reports in their own words, including feelings, complaints, and symptom descriptions. Example: “Client stated she has been feeling anxious every morning before work.”
Objective (O): What the therapist directly observes: appearance, mood, affect, behavior, and psychomotor activity. These are things a third party could see or measure. Example: “Client appeared tense, spoke rapidly, and made limited eye contact.”
Assessment (A): The therapist’s clinical interpretation. How is the client progressing? Are symptoms improving? Is there any risk? Example: “Client’s anxiety appears moderately elevated, consistent with reported life stressors.”
Plan (P): What you are doing next: session focus, homework, any referrals, medication follow-ups, or adjustments to how you are working with the client.
SOAP Notes Example
Client: Adult female, 34 | Diagnosis: Generalized Anxiety Disorder
Subjective: Client said anxiety has been worse this week, rating it 8/10. She kept coming back to fears about losing her job. Sleep has been off, and focus at work is suffering.
Objective: Client presented as alert and oriented. Appeared visibly tense with raised shoulders and frequent fidgeting. Speech was rapid. Mood was anxious, and affect matched. No signs of psychosis. No suicidal ideation.
Assessment: Anxiety is still sitting at moderate to severe. Job-related worry is driving most of it, and catastrophic thinking came up repeatedly. She has not made much ground yet toward her anxiety goals.
Plan: Staying with CBT and working on how she frames worst-case scenarios. Left with a thought record to fill out before next week. Sleep will be checked at the next visit. She brought up a psychiatry referral but decided against it for now.
When to Use SOAP Notes
- Works well in medical or integrated care settings
- Standard in hospital-based mental health programs
- Good fit when physicians or other providers are reading the same notes
- Useful anywhere documentation needs to be structured and easy to audit
DAP Notes
A DAP note, a type of progress note that puts the client’s report and your observations into one section called Data. You write less, cover the same ground, and still end up with a complete record. It is the go-to format in private practice and outpatient counseling for that reason.
DAP stands for Data, Assessment, and Plan. The three-section structure cuts redundancy and suits therapists who need to document efficiently across a full caseload.
DAP Note Format
Data (D): What the client said and what you observed, all in one place. This is what sets DAP apart from SOAP, where those two things are written separately.
Assessment (A): Your clinical take: how the client is progressing, what the diagnostic picture looks like, any risk factors, and how they are responding to treatment.
Plan (P): What comes next: session focus, interventions you plan to use, homework, referrals, or any changes to the treatment plan.
DAP Note Example
Client: Adult male, 28 | Presenting concern: Depression and social isolation
Data: Client came in and reported finishing his homework — he scheduled a social outing and actually went to a family dinner. Mood was 5/10, up from 3/10 the week before. Eye contact was better, and he seemed more present than usual. Still dragging in the mornings and struggling to stay motivated at work.
Assessment: The behavioral activation work is starting to land. His mood is ticking up, and he engaged socially twice this week. Negative self-talk around worthlessness is still there. No thoughts of suicide.
Plan: Keep building on social engagement. Start introducing ways to challenge the negative self-talk. Journaling is assigned to track mood alongside activity. Check in on progress next session.
Difference Between DAP and SOAP Notes
| Feature | SOAP Notes | DAP Notes |
| Structure | 4 sections (S, O, A, P) | 3 sections (D, A, P) |
| Subjective and Objective | Kept separate | Combined into Data |
| Complexity | More detailed | Faster to write |
| Best Use | Medical and team settings | Private practice, outpatient |
| Popularity | High in healthcare | High in counseling settings |
BIRP Notes
BIRP notes are a type of progress note that documents what the therapist did and how the client responded, making them the right format for behavioral health settings where tracking outcomes matters.
BIRP stands for Behavior, Intervention, Response, and Plan. Unlike SOAP or DAP, BIRP leads with what the client presented behaviorally, then records what the therapist did about it. Community mental health centers and intensive programs use BIRP notes for mental health documentation regularly because they produce a clear record of clinical action and result.
BIRP Format Explained
Behavior (B): The client’s presenting behavior, mood, and reported concerns at the start of the session.
Intervention (I): What you actually did in session. Name the technique and describe how you used it, not just what it is called.
Response (R): What happened when you used it? Did the client engage, push back, or shift in some way? This is where you show the intervention had an effect.
Plan (P): What you are carrying into the next session: what to keep, what to adjust, what to introduce.
BIRP Notes Example
Client: Adolescent female, 16 | Diagnosis: ADHD, Oppositional Defiant Disorder
Behavior: Client appeared irritable and defensive at the session start. She stated, “I don’t see why I have to be here.” Therapists observed tight body language and a raised affect. A client brought up a run-in with a teacher that ended in detention.
Intervention: Used motivational interviewing to explore what she actually wants for herself. Walked through the school situation together and looked at where her reaction made things escalate. Tried out a different response using role play.
Response: She pushed back at first, but got into it once the role play started. By the end, she admitted her reaction had made things worse and picked one thing she was willing to do differently.
Plan: Keep going with motivational interviewing. Work on self-regulation again next session. Reach out to the school counselor once the client gives the go-ahead. Next session is on the books.
When Therapists Use BIRP Notes
- Programs where you need to show measurable progress
- High-acuity community mental health caseloads
- IOPs and PHPs
- Any billing situation where you have to document what you did and how the client responded
GIRP Notes
GIRP notes are a type of progress note that anchors every section of the documentation to a specific treatment goal, making them a natural fit for structured programs where clinical accountability is built into the model.
GIRP stands for Goal, Intervention, Response, and Plan. Substance use programs, rehab centers, and structured outpatient settings tend to use GIRP because every note ties directly back to a treatment goal. You can track progress week by week without losing the thread.
Goal (G): The specific goal you are working on today, pulled word for word from the treatment plan.
Intervention (I): What you did in the session to move toward that goal.
Response (R): How the client showed up for it. Did they engage? Did they struggle? What came out of it?
Plan (P): What happens next in pursuit of the goal, including adjustments, continuations, or new objectives.
PIE Notes
PIE notes are a type of progress note that strips documentation down to three focused sections and are used in mental health settings where speed and simplicity matter.
PIE stands for Problem, Intervention, and Evaluation. The format originated in nursing and medical settings. It leads with the identified clinical problem rather than the client’s narrative, which keeps documentation tight. Case managers, inpatient psychiatric units, and high-volume settings where multiple providers document for the same client find PIE notes practical.
Problem (P): The clinical issue you are addressing today, tied to the client’s diagnosis or care plan.
Intervention (I): The specific thing you did about it in session.
Evaluation (E): Did it make a difference? Document the client’s response and any shift in their status.
PIE Note Example (Mental Health)
Problem: Client came in anxious about an upcoming court date.
Intervention: Walked through diaphragmatic breathing and a grounding exercise together. Talked through how anxiety builds and why the body reacts the way it does.
Evaluation: Anxiety dropped from 7/10 to 4/10 by the end of the session. Client said she felt steadier. Will practice again next time.
DARP Notes
DARP notes a type of progress note that extends DAP by adding a Response section that captures how the client reacted to in-session interventions, which standard DAP does not document.
DARP stands for Data, Assessment, Response, and Plan. It sits between DAP and BIRP: more detail than DAP, less structure than BIRP. Clinicians managing complex cases who need documented proof of intervention response without adopting a full behavioral framework find DARP notes useful.
Data (D): Combined client report and therapist observations from the session.
Assessment (A): Clinical interpretation: progress, risk, diagnostic impressions, and treatment response.
Response (R): How the client responded to the therapist’s interventions during the session. This is what separates DARP from standard DAP.
Plan (P): Next session objectives, homework, referrals, or plan adjustments.
DARP is a good fit when:
- Billing or supervision requires documented proof of intervention response
- You are moving from DAP toward BIRP and need a transitional format
- Case complexity needs more clinical detail than DAP alone provides
APSO Notes
APSO notes put the clinical assessment first, so the reader sees your conclusion before the supporting data, which makes them efficient in fast-paced or medical environments.
APSO stands for Assessment, Plan, Subjective, and Objective. It is a reordered version of SOAP. In settings where providers read notes quickly and need conclusions at the top, the APSO format reduces reading time without losing clinical content.
Assessment (A): Your clinical interpretation comes first.
Plan (P): The treatment plan follows directly after.
Subjective (S): Then the client’s own report: what they said, described, and experienced.
Objective (O): Finally, your direct observations from the session.
APSO works best when:
- Providers are reading notes quickly and need conclusions at the top
- You work in an integrated or medical setting with time-pressured colleagues
- The clinical audience reads selectively and values efficiency
How to Write Therapy Progress Notes (Step-by-Step)
Writing good therapy progress notes requires a consistent process. These four steps apply across all formats and keep documentation accurate, compliant, and efficient.
Step 1 — Capture Subjective Information
Start with what the client reported during the session. Write in third-person clinical language throughout. “Client reported feeling overwhelmed” is correct. “She said she’s overwhelmed” is not.
Include:
- Mood and energy level as reported by the client
- Symptoms mentioned: sleep, appetite, concentration, anxiety, etc.
- Significant life events or stressors since the last session
- Direct quotes, used sparingly, when they carry clinical weight
Step 2 — Document Objective Content
Objective content therapy notes examples should only include what is directly observable and measurable, things a third party could verify.
Avoid vague descriptors like “seemed sad.” Write instead: “Client’s affect was flat; she made minimal eye contact and spoke in a monotone.”
Document:
- General appearance: grooming, dress, hygiene
- Psychomotor activity: agitation, slowing, restlessness
- Speech: rate, volume, coherence
- Mood as reported and affect as observed
- Thought process and content: logical, tangential, disorganized, etc.
- Cognitive functioning: orientation, memory, concentration
Step 3 — Write Clinical Assessment
The assessment section is where your clinical judgment goes. Connect the session data to a clinical conclusion. Do not just summarize what happened; explain what it means for the client’s care.
Include:
- Progress toward specific treatment goals
- Clinical interpretation of patterns or themes from the session
- Risk assessment: document suicidal ideation, self-harm, or substance concerns explicitly, even when denied
- Diagnostic impressions if symptoms are shifting or new concerns emerge
- The client’s response to the interventions used in the session
Step 4 — Create the Treatment Plan
Every therapy progress note should close with a specific, action-oriented plan. “Continue therapy” is not a plan. “Continue CBT focusing on decatastrophizing; client will complete a daily thought record before next session.
Checklist for the plan section:
- Next session date and focus area
- Homework or between-session tasks assigned
- Modality or technique to be used in the next session
- Referrals made or pending
- Medication follow-up if applicable
Real Therapy Progress Notes Examples
Three sample progress notes for therapy, one per format, written in realistic clinical language.
Example 1 — SOAP Progress Note
Client: Adult male, 42 | Diagnosis: Major Depressive Disorder, recurrent, moderate
Subjective: Client said this week was hard. He mentioned sleeping 12 hours a day and still feeling drained. He does not feel ready to go back to work. No suicidal thoughts. Appetite is unchanged.
Objective: Looked unkempt. Spoke slowly with long pauses. Flat affect. Poor eye contact. Called his mood “empty.” No agitation or unusual perceptions noted.
Assessment: Depression is still moderate to severe. He is sleeping too much, moving slowly, and not engaging much with treatment. Work functioning is down. No safety concerns right now.
Plan: Keep going with interpersonal therapy around work and life changes. He agreed to a 10-minute walk each day as a starting point. Sent referral to psychiatry for a medication check. Back in one week.
Example 2 — DAP Progress Note
Client: Adult female, 29 | Diagnosis: PTSD, Panic Disorder
Data: Client appeared more engaged than in the last session. She tried her grounding exercise during a panic attack this week and said it helped somewhat, bringing panic from 9/10 to 6/10. A work situation brought up memories related to her trauma. Eye contact and speech were noticeably better. No avoidance reported.
Assessment: Grounding skills are starting to work. PTSD symptoms are still present, but she is making the connection between current triggers and past trauma. That is a good sign for starting EMDR. No safety concerns.
Plan: Start EMDR phase 1 psychoeducation in the next session. Keep practicing grounding skills. Assigned a body scan to try at home. Talked through how to handle the work event coming up. Next session is confirmed.
Example 3 — BIRP Progress Note
Client: Adult male, 51 | Diagnosis: Alcohol Use Disorder, Moderate
Behavior: Client walked in, rattled. He had been drinking again, four times over the past week, after three clean weeks. Said he just gave up. Kept his eyes down and barely spoke above a whisper. No safety concerns.
Intervention: Used motivational interviewing to look at the relapse without blame. Did a decisional balance exercise to weigh drinking versus staying sober. Talked through what situations put him at risk and what coping options he had but did not use.
Response: He opened up more as the session went on. Named two triggers he had never mentioned before. Admitted he did not follow his coping plan when things went sideways.
Plan: Rework the relapse prevention plan to include the new triggers. Practice the coping responses together next session. Get his AA sponsor looped in for backup. He committed to two meetings this week. Next session booked.
Common Mistakes to Avoid When Writing Progress Notes
These documentation errors are the most common and the most damaging to avoid when writing progress notes.
- Being too vague: “Client doing well” and “Session was productive” have no clinical value. Notes need specific, observable detail.
- Over-documenting: A progress note is not a session transcript. Comprehensive means covering what matters, not everything that was said.
- Missing risk documentation: If you assess safety, document it. Write “Client denied suicidal ideation” even when the answer is no.
- Mixing subjective and clinical language: “Client is depressed” is a clinical conclusion. “Client reported feeling depressed” is documentation. Know the difference.
- Copy-pasting previous notes: Reusing prior notes without updating them is a HIPAA violation and a red flag in any audit.
- Incomplete signatures: Full name, credentials, and date of service must appear on every note. Missing any of these can trigger a denied claim.
- Late documentation: Notes written days after a session are harder to defend. Write them the same day.
Best Practices for Faster, Compliant Documentation
These habits cover how to write therapy notes quickly without cutting clinical corners.
- Write immediately after each session or within 24 hours. The longer you wait, the less accurate the note becomes.
- Use a template for your chosen format. Templates eliminate blank-page hesitation and keep notes consistent across your caseload.
- Keep language clinical throughout. No slang, no unexplained abbreviations, no casual phrasing.
- Keep progress notes and psychotherapy notes separate. Personal impressions and countertransference belong in a different document.
- Know your payer requirements. Medicare, Medicaid, and private insurers each have their own documentation standards.
- Only document what actually happened. Do not record interventions you did not use or observations you did not make.
- Protect third-party information. Do not include details about people other than the client without their consent.
Conclusion
Choosing the Right Format for Your Practice
The right type of therapy progress note depends on where you work, who you serve, and what your billing and compliance requirements are.
SOAP fits structured medical environments. DAP suits outpatient counseling and private practice. BIRP is built for behavioral health and outcome tracking. GIRP keeps documentation tied to treatment goals. PIE works in fast-paced or team-based settings. DARP adds intervention tracking to the DAP structure. APSO is for clinicians who need conclusions first.
Use your chosen format consistently. Inconsistent documentation is harder to audit, harder to defend, and harder to rely on as a clinical tool.
FAQs About Therapy Progress Notes
What are the different types of progress notes?
The seven types are SOAP, DAP, BIRP, GIRP, PIE, DARP, and APSO. Each suits a different clinical setting and documentation purpose. The right choice depends on your treatment environment and billing requirements.
What is the difference between SOAP and DAP notes?
SOAP keeps the client’s report and therapist’s observations in separate sections. DAP combines them into one Data section, making it faster to write. SOAP fits medical and team settings; DAP fits outpatient counseling and private practice.
What does BIRP stand for?
BIRP stands for Behavior, Intervention, Response, and Plan. It tracks what the therapist did and how the client responded, making it ideal for behavioral health programs that need to document measurable outcomes.
What should be included in a therapy progress note?
Every note needs the client’s self-report, the therapist’s observations, a clinical assessment, and a clear treatment plan. Also include risk assessment, modality used, and a signed date with credentials.
How long should progress notes be?
Most therapy progress notes run between 150 and 500 words. Length should reflect the clinical complexity of the session, not habit. Avoid padding, but do not leave out anything essential.
