Mental Health Progress Note Templates and Examples

Writing clear, clinically useful progress notes can be one of the most time-consuming parts of your day. Whether you use SOAP, BIRP, DAP or another structure, the challenge is always the same: capturing what happened in the session, why it matters, and how it informs treatment — all while staying present with your client.

This guide brings together the most commonly used progress note templates and progress note examples across psychotherapy, counseling and behavioral health settings. You’ll find easy-to-follow structures, clinical tips, and real-world examples you can adapt to your workflow.

What Are Progress Notes?

Progress notes document what occurred in a therapy session, how the client is responding to treatment, and what the next steps are. They support continuity of care, clinical decision-making and communication across a team. They are not meant to be transcripts — they should be concise, objective and tied to the treatment plan.

You’ll also see terms like therapy progress notes, psychotherapy progress notes, mental health progress notes, and behavioral health progress notes used interchangeably. The format you choose often depends on your setting, modality, supervisor expectations or insurance requirements.

Popular Therapy Progress Note Templates

Below are the most widely used therapy note formats in mental health practice, with simple breakdowns you can use immediately.

SOAP Progress Note Template

S – Subjective
Client’s report of symptoms, concerns, emotional state and relevant context.

O – Objective
Observable behaviors, mental status exam elements, risk indicators, clinician observations.

A – Assessment
Clinical impressions, diagnostic considerations, client progress and response to interventions.

P – Plan
Next steps, homework, referrals, safety planning, follow-up actions.

SOAP Progress Note Example

S: Client reports increased anxiety at work, especially during meetings.
O: Appeared tense, avoided eye contact, fidgeted throughout session.
A: Anxiety symptoms consistent with GAD; client continues to engage actively in CBT strategies.
P: Continue CBT; assign thought log; review coping strategies next session.

DAP Progress Note Template

D – Data
Subjective and objective information from the session.
A – Assessment
Clinical interpretation and progress.
P – Plan
Interventions, recommendations and next steps.

DAP Progress Note Example

D: Client described difficulty sleeping and increased irritability. Affect anxious but engaged.
A: Symptoms linked to work stress; moderate progress toward goals.
P: Introduce relaxation exercise; assess sleep patterns next session.

BIRP Progress Note Template

B – Behavior
Client’s reported and observed behaviors.
I – Intervention
What the therapist did (skills taught, questions asked, tools introduced).
R – Response
How the client responded to the intervention.
P – Plan
Future actions and follow-up.

BIRP Progress Note Example

B: Client described panic symptoms occurring twice this week.
I: Introduced grounding technique and practiced in session.
R: Client was able to reduce distress from 7/10 to 4/10 during practice.
P: Continue exposure plan; monitor panic frequency.

PIRP Progress Note Template

P – Problem
The issue or concern addressed.
I – Intervention
Therapeutic approach used.
R – Response
Client progress or reaction.
P – Plan
Next steps.

Psychotherapy Progress Notes

Psychotherapy progress notes focus on psychological symptoms, emotional processes, and therapeutic work tied to modalities like CBT, ACT, psychodynamic therapy, EMDR and more. They typically emphasize:

• Client’s emotional state and patterns
• Insight or shifts in understanding
• Cognitive or behavioral interventions
• Risk assessment when relevant
• Treatment plan alignment

Example (CBT context):
A: Client identified core belief of “I’m incompetent” influencing workplace anxiety. Demonstrated ability to challenge distorted thoughts during cognitive restructuring.

Counseling Progress Notes

Counseling progress notes are often used in settings like community agencies, school counseling, college counseling centers, and private practices focusing on life stressors, adjustment and skills development. They tend to highlight:

• Presenting problems (stress, relationships, academic challenges)
• Skill-building and coaching
• Goal tracking
• Strengths-based perspectives

Example:
I: Explored communication patterns with partner and practiced assertive statements.
R: Client reported increased confidence using skills at home.

Behavioral Health Progress Notes

Behavioral health progress notes are used across integrated care, substance use treatment, hospital-based programs or multidisciplinary teams. They often incorporate:

• Behavior tracking
• Functional impact
• Medication adherence (when relevant)
• Safety and risk monitoring
• Collaboration across providers

Example:
O: Client denies suicidal ideation; reports adherence to prescribed medication.
A: Symptoms stable; no acute risk noted.

Full Progress Note Example (Complete Template)

Below is a combined example that mirrors real-world documentation across therapy, counseling and behavioral health settings.

Client: Individual adult
Modality: CBT
Presenting concern: Anxiety and avoidance

Subjective: Client reports avoiding two social events due to fear of judgment. Feels disappointed and isolated.
Objective: Affect anxious; speech coherent; no safety concerns raised.
Assessment: Avoidance behaviors continue to reinforce anxiety cycle. Client is motivated and engaged in learning skills.
Plan: Continue exposure hierarchy; assign graded task for the week; review progress in next session.

Therapy Note Formats Compared

How to Write Progress Notes: Clinical Tips

• Keep language objective and concise
• Reflect the client’s progress toward treatment goals
• Tie each session to the treatment plan
• Document interventions clearly
• Record client responses, not just your actions
• Include any changes in symptoms, risk or functioning
• Avoid unnecessary detail or verbatim dialogue

How to Write Progress Notes That Meet Medical Necessity

Medical necessity is a key requirement in many clinical, insurance and healthcare settings. Writing notes that meet this standard helps ensure continuity of care and protects clinical decisions.

Here’s what to include:

1. Clear link to the diagnosis or clinical concern

Describe how the session content connects to symptoms, impairments or treatment goals.

2. Evidence of functional impact

Note how the client’s condition affects daily functioning, relationships, work or school.

3. Documented therapeutic intervention

Specify what you did — CBT techniques, exposure work, grounding skills, insight-oriented exploration, etc.

4. Client response and progress

Show whether the client is improving, stagnating or regressing, and how they responded in session.

5. Next clinically appropriate step

Your plan should reflect a logical continuation of care: more sessions, referrals, safety planning, homework, or treatment adjustments.

How Emosapien Helps Therapists Write Better Progress Notes

Emosapien can draft session notes in real time so you stay present with your client while documentation builds in the background. After the session, you review and finalize in minutes — without starting from scratch. The structure is aligned with your preferred format (SOAP, DAP, BIRP) and grounded in your treatment plan, helping you meet clinical, ethical and medical-necessity standards with less effort.

Summary

Whether you prefer SOAP, DAP, BIRP or another style, progress notes don’t need to be overwhelming. Clear templates, grounded examples and a consistent structure make it easier to capture what matters: your client’s progress and the clinical reasoning guiding your work.