Many therapists and counselors search for a concrete mental health progress note example they can compare their own documentation against — something that reflects real clinical work rather than a stripped-down illustration. A useful example shows not just the structure but the level of clinical detail that belongs in each section.
This article provides a realistic mental health progress note example in a neutral format, followed by the same clinical scenario documented in SOAP, DAP, and BIRP formats. It also covers what makes a note clinically useful, common documentation mistakes, and how some clinicians streamline their post-session workflow.
A mental health progress note is a clinical document written after each therapy or counseling session. It records what happened in the session at a clinical summary level — what the client reported, what interventions were used, how the client responded, and what is planned next. Progress notes are part of the official medical record, which means they may be shared with other treating providers, reviewed by insurance payers, or disclosed in response to a standard records request.
Progress notes serve clinical, continuity, and insurance purposes. Clinically, they document the treatment course and inform ongoing treatment planning. For continuity of care, they ensure that if a client transfers to another provider, that provider can understand the client's history and current status. For insurance, they serve as evidence that services were rendered and that treatment is medically necessary.
It is important to distinguish progress notes from psychotherapy notes. Under HIPAA, psychotherapy notes (also called process notes) are a separate legal category — they contain the therapist's personal observations and impressions and are kept separately from the medical record. They have stronger privacy protections and are not equivalent to progress notes, even though both documents relate to therapy sessions.
The following is a realistic mental health progress note for a client presenting with depression and grief following a significant loss. It is written in a structured neutral format — not labeled as SOAP, DAP, or BIRP — and illustrates the level of clinical detail appropriate for a routine outpatient session. All identifying information is de-identified.
Client attended the sixth individual session. Primary focus was ongoing grief following the death of their parent three months ago, with particular attention to guilt cognitions that have emerged over the past two weeks.
Client reported persistent low mood, insomnia, and social withdrawal. Described increased guilt related to circumstances of the death, including intrusive thoughts about things left unsaid. Affect was tearful at the start of session and gradually shifted toward reflective as the session progressed. No safety concerns identified.
Grief-focused cognitive behavioral therapy. Socratic questioning was used to examine and restructure guilt-laden cognitions. Therapist introduced a two-chair dialogue exercise to facilitate processing of unfinished emotional business. Psychoeducation was provided on the relationship between guilt and grief.
Client engaged meaningfully with the two-chair exercise and demonstrated initial insight into patterns of self-blame. Identified two alternative interpretations of the guilt-triggering event by end of session. Progress toward treatment goals related to grief processing is emerging.
Assign between-session reflective journaling on guilt cognitions. Continue grief-focused CBT at next session, with further exploration of avoidance behaviors. Reassess sleep and appetite. Weekly sessions to continue.
Many clinicians use a structured note format to organize documentation consistently. The three most widely used formats in outpatient mental health are SOAP, DAP, and BIRP. Each covers the same core clinical content but organizes it differently. Below are brief examples of the same grief/loss scenario documented in each format. For full examples and templates, follow the links at the bottom of each card.
SOAP notes separate the client's self-report (Subjective) from clinician observations (Objective), then add an Assessment of clinical status and a Plan for next steps. This is a widely recognized format across behavioral health settings.
Client reports persistent low mood and difficulty concentrating since the death of their parent three months ago. States they have been isolating and describes feelings of emptiness and guilt.
Client appeared tearful at the start of session; affect was constricted and affect range was limited throughout. Speech was slow but coherent. No safety concerns.
Presentation consistent with major depressive episode in context of complicated grief. Client is engaging meaningfully in grief-focused work and demonstrating early capacity to tolerate painful affect in session.
Continue grief-focused CBT interventions. Explore meaning-making around the loss at next session. Weekly sessions to continue. Reassess PHQ-9 at next visit.
See the full example and template: SOAP Note Example for Therapy.
DAP notes combine client self-report and clinician observations into a single Data section, then follow with Assessment and Plan. Many clinicians find this format faster to write for routine outpatient sessions.
Client reported ongoing grief symptoms including insomnia, low appetite, and social withdrawal. Disclosed that they had avoided the deceased's bedroom for three months. Affect was tearful; client became more animated when recalling positive memories of their parent later in session.
Client continues to meet criteria for complicated grief. Avoidance behaviors persist but client shows emerging capacity to approach grief-related stimuli. Early progress toward treatment goals.
Introduce graduated exposure to avoided memories and spaces. Assign between-session journaling exercise. Continue weekly sessions.
See the full example and template: DAP Note Example for Therapy.
BIRP notes center the documentation on what the therapist did and how the client responded, making them particularly useful for demonstrating medical necessity. The Behavior section documents client presentation; Intervention names techniques used; Response captures the client's reaction.
Client arrived reporting a difficult week marked by intrusive memories of deceased parent and increased crying spells. Reported sleeping 4-5 hours per night. Affect was tearful; engagement was cooperative.
Used grief-focused CBT to explore cognitive distortions around guilt and responsibility. Introduced two-chair dialogue technique to process unfinished emotional business. Provided psychoeducation on normal grief versus complicated grief.
Client engaged actively with two-chair exercise and expressed insight into self-blame patterns. Affect shifted from tearful to reflective by end of session. Demonstrated capacity for emotional regulation.
Assign reflective journaling on guilt cognitions. Continue grief-focused CBT at next session. Reassess sleep at follow-up.
See the full example and template: BIRP Note Example for Therapy.
For a broader overview of progress note examples across formats, see Therapy Progress Note Example.
A well-written progress note does more than satisfy a documentation requirement. It creates a useful clinical record. These are the qualities that make a mental health progress note clinically meaningful:
Captures the client's current clinical status — mood, affect, presenting concerns, and any changes since the last session
Documents what interventions were used — specific enough that another clinician could understand the treatment approach
Shows progress toward treatment goals — noting gains, setbacks, or stability against the goals in the treatment plan
Provides continuity of care information — sufficient detail that the note could inform another provider if needed
Is specific enough to support insurance review — avoiding vague entries that would not demonstrate medical necessity
These patterns reduce the clinical and compliance value of progress notes and are common across mental health settings:
Writing sessions as narrative stories rather than clinical summaries
Progress notes are clinical documents, not diary entries. A note should distill the session to its clinically significant elements — what the client reported, what interventions were used, what shifted — not recount the session chronologically from start to finish.
Omitting the therapist's clinical assessment
A note that records what the client said without any clinical interpretation leaves out the clinician's professional judgment. The Assessment section (or equivalent) is where the therapist documents their understanding of the client's current status, functioning, and progress — essential for demonstrating skilled care.
Leaving the Plan section empty or generic
Entries like 'continue current treatment' provide no useful clinical information. The Plan should specify what interventions or techniques will be used at the next session, any between-session assignments, and next appointment details.
Writing notes from memory days after the session
The longer the gap between session and documentation, the more detail is lost. Clinicians who write notes from end-of-week recall tend to produce more generic documentation that misses clinically significant moments. Even a brief summary captured immediately after the session provides much better raw material for the formal note.
A workflow that many clinicians find effective is to separate capturing the session from formatting the note. Immediately after a session, rather than writing a full structured note from scratch, they speak or type a brief post-session summary — two to four sentences covering what the client reported, what interventions were used, how the client responded, and what the plan is. That raw summary becomes the source material for the formal structured note, rather than relying on recall hours later.
Some clinicians use tools like AfterSession to convert those session summaries into structured progress notes in SOAP, DAP, BIRP, or other formats. The clinician reviews and edits the draft before saving. No sessions are recorded; the therapist provides a post-session summary in their own words and remains the author of every note.
At minimum, a mental health progress note should document: the client's presenting concerns and current clinical status, what interventions the clinician used during the session, the client's response and any observed clinical changes, progress toward treatment goals, and the plan for the next session. Many payers have specific content requirements — review your contracts to confirm what must be present for reimbursable services.
These are legally distinct document types under HIPAA. A mental health progress note (also called a clinical note or session note) is part of the official medical record. It documents session content at a clinical summary level and may be shared with other providers, insurers, or disclosed in response to a standard records request. A psychotherapy note is a separate document containing the therapist's personal process observations — raw impressions, hypotheses, countertransference material, verbatim session content. Psychotherapy notes have stronger privacy protections under HIPAA: a standard authorization form is not sufficient to compel their release.
Yes, in most cases. Insurance payers typically require progress notes as part of the clinical record for covered services. Notes may be audited to verify that services were rendered, that they were medically necessary, and that documented treatment aligns with the client's diagnosis and treatment plan. Requirements vary by payer — review your provider agreements and, if applicable, your state Medicaid documentation requirements for specifics.
There is no universal required length. Most outpatient mental health progress notes are one to two paragraphs or the equivalent in a structured format like SOAP, DAP, or BIRP. A note should be detailed enough to be clinically meaningful — documenting what happened, your clinical assessment, and what comes next — but not so long that it becomes a session transcript. If notes routinely take more than 10-15 minutes for a standard session, the level of detail may be more than necessary.
A strong mental health progress note serves the client, the clinician, and the clinical record at once. It captures what actually happened in the session in a form that is useful for continuity of care, meaningful for treatment planning, and sufficient for insurance documentation. The examples above are meant to give you a concrete reference for the level of clinical detail that belongs in each section.
Whether you use a neutral summary format, SOAP, DAP, BIRP, or another structured approach, consistency matters more than format choice. Clinicians who document with a consistent structure write notes faster, produce more complete records, and spend less cognitive energy deciding what to include each time.
A realistic therapy progress note example with a reusable template, format comparisons (SOAP, DAP, BIRP), common documentation mistakes, and tips for writing session notes faster.
A realistic SOAP note example from a therapy session, with a reusable template, common documentation mistakes to avoid, and tips for writing notes faster.
A realistic DAP note example from a therapy session, with a reusable template, common documentation mistakes to avoid, and tips for writing notes faster.
Summarize your session in your own words. AfterSession turns it into a structured SOAP, DAP, or BIRP note that you review and save. No recordings required.
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