Progress notes are written after every session. They're part of the permanent clinical record, serve as the documentation of treatment provided, and in many settings are what insurers review to authorize continued care. Writing them from scratch each time is one of the most common sources of documentation fatigue.
Having a consistent template changes the experience. Instead of deciding what to include and how to organize it, you're filling in a structure you already know — which reduces decision fatigue, speeds up writing, and produces more consistent notes across your caseload. This page provides a reusable template, a filled-in example, phrase starters, and guidance on adapting the template to standard note formats.
A therapy progress note is the clinical record of a single session. It documents the client's presenting concerns, the interventions used, the client's response, and the plan for continued treatment. Progress notes serve multiple purposes: they create a continuous clinical record across the treatment relationship, support insurance documentation by demonstrating medical necessity and goal-directed care, and enable continuity of care if another provider needs to step in.
Progress notes are part of the medical record under HIPAA, which means they can be shared with other providers, insurers, and in some cases the client. This is distinct from psychotherapy notes — the private process notes that therapists keep separately — which have stronger privacy protections. Progress notes should be factual, clinically relevant, and professional in tone, since they may be read by audiences beyond the treating clinician. See the therapy progress note example for additional context on what completed notes look like in practice.
This template captures the core sections of a progress note. The bracketed prompts indicate what belongs in each section — replace them with your session-specific content. The template is format-agnostic and can be adapted to SOAP, DAP, BIRP, or any other structure your practice uses.
Session Date: [Date] Client: [Initials or ID] Session Length: [Duration] Session Type: [Individual / Group / Telehealth] Session Summary: [1–2 sentences capturing the overall focus and tone of the session.] Client Concerns: [What the client reported — presenting issues, mood, notable events since last session, changes in symptoms.] Interventions Used: [Specific techniques and modalities — e.g., cognitive restructuring, motivational interviewing, psychoeducation, exposure work.] Client Response: [How the client responded — engagement level, insights, emotional shifts, resistance, or observed progress.] Progress Toward Treatment Goals: [Brief statement on movement toward goals. Note gains, setbacks, or changes in clinical status.] Plan for Next Session: [Specific next steps — interventions to continue or introduce, between-session assignments, referrals, next appointment date.]
Below is a completed example using the template above. The session depicted is a routine individual session addressing anxiety. Notice that each section is specific without being exhaustive — the note captures what another clinician would need to understand the client's status and continue care.
[Date] | Client: T.M. | 50 minutes | Individual, telehealth
Session focused on managing anticipatory anxiety related to an upcoming social event. Client engaged actively throughout and showed increased willingness to apply previously learned coping strategies.
Client reported moderate anxiety (6/10) ahead of a work team event scheduled for next week. States: "I know I'll probably be fine but my brain keeps making it worse." Reports sleep has been adequate this week. No significant changes in mood or functioning since last session. No safety concerns.
1. Cognitive restructuring: identified and examined two automatic thoughts related to perceived social judgment at the event. 2. Behavioral rehearsal: walked through specific anticipated scenarios with client generating coping responses. 3. Grounding technique review (5-4-3-2-1) as a in-the-moment tool for day-of anxiety. 4. Psychoeducation reinforced: anxiety as prediction, not reality.
Client engaged readily with cognitive restructuring and identified one thought as "probably not realistic." Behavioral rehearsal produced visible shift in posture and tone — client appeared less tense by session end. Self-reported anxiety dropped to 4/10. Client stated: "I feel like I have a plan now." Good insight and motivation to follow through.
Goal: Reduce avoidance of social situations and develop active coping strategies for anxiety. Continued progress this session — client is applying cognitive tools with increasing independence and demonstrating ability to generate coping responses without extensive prompting. No new barriers identified.
1. Client to attend the team event and use grounding technique as needed. 2. Client to complete brief thought record if anxiety spikes before event. 3. Next session to debrief on event experience and assess for any avoidance patterns. 4. Continue weekly CBT targeting social anxiety. Next appointment: [date].
SOAP, DAP, and BIRP are structured variations of the same core content. The template above maps to each of them — the difference is how sections are labeled and organized:
SOAP — Adds an explicit Subjective/Objective distinction. Client-reported information goes in Subjective; your direct observations of behavior, affect, and appearance go in Objective. Assessment and Plan remain the same. Useful when that distinction matters clinically or is required by your payer.
DAP — Merges Subjective and Objective into a single Data section. This is a simpler structure for therapists who find the Subjective/Objective split cumbersome. Assessment and Plan follow. Widely accepted in outpatient mental health settings.
BIRP — Adds explicit Intervention and Response sections, making it easier to document what you did and how the client responded. Particularly useful for tracking intervention effectiveness across sessions. Behavior replaces Subjective/Data; Plan closes the note.
All three formats produce a note that covers the same clinical ground. Choosing one depends on your agency's requirements, payer expectations, or personal preference — not on which format is inherently superior.
These phrase starters are organized by section. They're meant to be adapted, not used verbatim — substitute your own clinical language and session-specific details.
SESSION SUMMARY examples: "Session focused on [topic]; client demonstrated [quality/shift]." "Primary session theme was [theme]; tone was [descriptor]." "This session addressed [presenting concern] in the context of [treatment goal]." CLIENT CONCERNS examples: "Client reported [symptom] rated [X]/10, with [change] since last session." "Client presented with [mood/affect], noting [specific concern or event]." "Client denied [safety concern/symptom]; reported [positive change or stable status]." INTERVENTIONS examples: "Cognitive restructuring targeting [specific thought pattern or belief]." "Motivational interviewing to explore ambivalence around [issue]." "Psychoeducation on [topic] to support [goal]." "Behavioral activation: identified [X] low-effort activities for between-session engagement." "Exposure work: [specific step in hierarchy] completed in session." CLIENT RESPONSE examples: "Client engaged [readily / with some resistance]; demonstrated [insight/shift]." "Client self-reported [emotion/rating] at session end, compared to [rating] at start." "Client stated: '[brief clinically relevant quote].'" "Client showed [behavioral/emotional indicator of progress or difficulty]." PLAN examples: "Client to [specific between-session task] before next session." "Continue [intervention] targeting [goal]; introduce [new element] if indicated." "Next session to focus on [topic]; follow up on [between-session task]." "Next appointment scheduled for [date]; [frequency] sessions to continue."}
Templates are a tool, not a shortcut. These patterns reduce the quality of the note even when the template itself is correct:
Using the same language session after session
Copy-pasting note content — even partial sentences — means the note stops reflecting what actually happened. Each session produces different clinical content and the note should reflect that.
Leaving Plan as 'continue therapy'
A plan that says only 'continue therapy' tells the next reader nothing about what will happen in the next session. Plans should name specific interventions, between-session tasks, or changes to the treatment approach.
Not updating the goals section
Progress toward treatment goals should be documented — and when goals change, updated. A note that references goals no longer relevant to the client's current presentation is less useful and potentially misleading.
Skipping Interventions detail
'Provided therapy' is not a documented intervention. Name the technique, modality, or approach used. Specific intervention language is more defensible and more useful for tracking treatment effectiveness.
Yes — using the same template structure is good practice. Templates reduce decision fatigue and ensure consistency across the treatment record. The goal is to vary the content, not the structure. Each session's clinical information should be fresh and specific; the template is just the scaffold that holds it.
Detailed enough to be clinically useful, concise enough to be sustainable. A practical benchmark: if another clinician read this note, could they understand the client's current status and continue care? If yes, the level of detail is probably right. If the note reads like a session transcript, it's likely over-documented. If it reads like a checklist with no clinical substance, it's under-documented.
Yes — using a template for structure is standard practice and is not a problem for insurance documentation. What matters to payers is whether the note documents medical necessity, goal-directed treatment, and clinical rationale for the services provided. A well-completed template does that. Clinicians should review their specific payer contracts for any format requirements.
Most documentation standards and payer requirements expect notes to connect to the treatment plan — which means referencing at least one treatment goal. Even a brief statement of progress toward a goal (or lack of it) keeps the note tied to the broader treatment context and demonstrates goal-directed care. When goals change, update them in the treatment plan and reflect the change in your notes.
A good progress note template is one of the simplest investments in documentation quality. It doesn't require you to write longer notes — just more consistent ones. When the structure is automatic, your attention goes to clinical content rather than organizational decisions, and notes get done faster without sacrificing specificity.
Use the template and phrase starters above as a starting point, and adapt them to fit your format, your clinical style, and your payer requirements. The goal is a note that is specific enough to be useful, consistent enough to track change over time, and concise enough to complete across a full caseload.
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.
Describe what happened in a session. AfterSession drafts a structured progress note you review and save — no recording required.
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