Therapy Session Note Template
Complete templates for documenting therapy sessions in SOAP and DAP formats. Includes component breakdowns, full examples, and best practices for mental health progress notes.
What to Include in a Therapy Session Note
A well-written therapy session note captures the essential clinical elements of the encounter while supporting continuity of care, medical necessity, and professional accountability. Regardless of whether you use SOAP or DAP format, every session note should include these five core components.
Client Presentation
Document the client's appearance, mood, affect, behavior, and overall mental status at the beginning of the session. Note any changes from previous sessions or anything clinically significant (e.g., "appeared more animated than previous session" or "tearful throughout").
Content Discussed
Summarize the main topics, themes, and content of the session. Include significant statements, disclosures, or insights. This section answers "what did you talk about?" without providing a verbatim transcript.
Interventions Used
Document the therapeutic techniques and interventions you employed during the session. Be specific about the type of intervention (cognitive restructuring, behavioral activation, psychoeducation, etc.) rather than generic terms like "provided support."
Client Response
Describe how the client responded to your interventions. Did they engage actively? Show resistance? Demonstrate insight? Have an emotional breakthrough? This section demonstrates the therapeutic process and client engagement.
Plan for Continued Treatment
Outline next steps, homework assignments, focus areas for the next session, and any changes to the treatment plan. Include referrals, coordination with other providers, or medication considerations if applicable.
When clinically indicated, document your assessment of suicide risk (SI) and homicide risk (HI). Even when denied, noting "Client denies SI/HI" demonstrates you assessed for safety. When risk is present, document the assessment, interventions (safety planning, crisis resources), and follow-up plan.
SOAP vs DAP Format for Therapy Notes
Mental health professionals commonly use either SOAP or DAP format for session documentation. Both are widely accepted by insurance companies and regulatory bodies. The choice often depends on your practice setting, employer requirements, or personal preference.
SOAP Format
- S - Subjective: Client's self-report, symptoms, concerns
- O - Objective: Clinician observations, mental status, interventions
- A - Assessment: Clinical interpretation, progress, diagnosis
- P - Plan: Treatment plan, homework, next steps
Best for: Integrated healthcare settings, psychiatry, when insurance requires SOAP format
DAP Format
- D - Data: All session information combined (what client said, what you observed, interventions used, responses)
- A - Assessment: Clinical interpretation, progress, diagnosis
- P - Plan: Treatment plan, homework, next steps
Best for: Private practice, counseling centers, when the S/O distinction feels artificial
In therapy settings, the distinction between "subjective" (what the client says) and "objective" (what you observe) can feel artificial since most information comes from therapeutic dialogue. DAP acknowledges this by combining everything into a single Data section. However, if your practice or insurance contracts require SOAP format, it works just as well for therapy documentation.
For a detailed comparison with side-by-side examples, see our SOAP vs DAP Notes guide.
Complete SOAP Format Template for Therapy
Use this template as a guide for structuring your therapy session notes in SOAP format. Adapt the specific content to match your session and clinical context.
SOAP Note Template - Therapy Session
S - Subjective
Document what the client reports about their symptoms, concerns, experiences, and progress since the last session.
- Chief complaint or presenting concern for this session
- Client's self-reported mood and symptoms (with ratings if applicable)
- Progress on homework or between-session goals
- Significant life events since last session
- Sleep, appetite, energy level changes
- Safety assessment (SI/HI) - client's statements
Example: "Client reports 'feeling more hopeful this week' with mood rated 6/10 (up from 4/10 last session). States she completed the thought record homework and found it 'eye-opening to see my patterns.' Reports one difficult day on Wednesday after conflict with coworker but was able to use coping skills. Sleep improved to 6-7 hours/night. Denies SI/HI."
O - Objective
Document your clinical observations and the interventions you used during the session.
- Appearance and hygiene
- Behavior (eye contact, psychomotor activity, engagement)
- Mood and affect (client-stated mood / observed affect)
- Speech (rate, volume, tone)
- Thought process and content
- Insight and judgment
- Standardized measures if administered (PHQ-9, GAD-7, etc.)
- Interventions used during session
Example: "Appearance: Appropriately dressed, good hygiene. Behavior: Good eye contact, engaged throughout, less fidgeting than previous sessions. Mood/Affect: 'Hopeful' / congruent, full range, appropriate. Speech: Normal rate, rhythm, volume. Thought process: Linear, goal-directed. Thought content: No delusions or obsessions. Insight: Good - recognizes cognitive patterns. Judgment: Good. GAD-7: 8 (moderate, down from 12). Interventions: Reviewed thought record homework, cognitive restructuring for workplace anxiety, introduced behavioral experiment for feared situation."
A - Assessment
Provide your clinical interpretation of the session and the client's overall progress.
- Diagnosis (with ICD-10 code if required)
- Progress toward treatment goals
- Clinical impressions and conceptualization
- Risk assessment summary
- Therapeutic alliance
Example: "Generalized Anxiety Disorder (F41.1), moderate severity, improving. Client demonstrating good progress with cognitive restructuring skills, as evidenced by 4-point decrease on GAD-7 and successful application of coping skills during stressful situation. Therapeutic alliance remains strong. No acute safety concerns. Continue current treatment approach with focus on behavioral activation and workplace anxiety."
P - Plan
Outline the plan for continued treatment and next steps.
- Frequency and modality of continued treatment
- Focus areas for next session
- Homework assignments
- Referrals or coordination with other providers
- Safety plan updates if applicable
- Next appointment
Example: "Continue weekly individual psychotherapy. Next session: Process outcome of behavioral experiment, continue workplace anxiety focus, introduce assertive communication skills. Homework: (1) Complete behavioral experiment - initiate one conversation with coworker, (2) Continue daily thought records, (3) Practice 4-7-8 breathing when noticing anxiety. Follow up in 1 week."
Complete DAP Format Template for Therapy
The DAP format combines all session information into a single Data section, which many therapists find more natural for documenting talk therapy sessions.
DAP Note Template - Therapy Session
D - Data
Document everything that occurred during the session: what the client reported, what you observed, topics discussed, interventions used, and client responses.
- Client presentation (appearance, behavior, affect)
- Client's self-report (mood, symptoms, concerns)
- Topics and themes discussed
- Interventions used and client response
- Safety assessment
- Standardized measures if administered
Example: "Client presented for individual therapy session. Appearance appropriate with good hygiene. Good eye contact and engagement throughout session, notably less anxious presentation than previous sessions.
Client reported feeling 'more hopeful this week' with self-rated mood 6/10 (up from 4/10). Completed thought record homework and found it 'eye-opening to see my patterns.' Described one difficult day on Wednesday after conflict with coworker but successfully used coping skills to manage anxiety. Sleep improved to 6-7 hours/night. GAD-7 score: 8 (moderate, decreased from 12 at last session). Denies SI/HI.
Session focused on reviewing thought record homework and identifying cognitive distortions related to workplace situations. Utilized cognitive restructuring to challenge catastrophic thoughts about coworker's perception. Client demonstrated good insight, stating 'I can see how I jump to conclusions.' Introduced concept of behavioral experiment for feared social situation. Client initially expressed hesitation but engaged in planning exercise and agreed to attempt before next session. Provided psychoeducation on assertive vs. passive communication styles."
A - Assessment
Provide your clinical interpretation and assessment of progress.
- Diagnosis and current severity
- Progress toward treatment goals
- Clinical impressions
- Risk level
- Treatment response
Example: "Client demonstrates meaningful progress with GAD, as evidenced by 4-point decrease on GAD-7 and self-reported improvement in daily functioning. Successfully applying cognitive skills learned in therapy to real-world situations. Behavioral experiment will help generalize anxiety management to social interactions. Strong therapeutic alliance supports continued progress. No acute safety concerns; risk low."
P - Plan
Outline next steps for treatment.
- Treatment frequency and modality
- Next session focus
- Homework assignments
- Referrals if applicable
- Follow-up timeline
Example: "Continue weekly individual psychotherapy, CBT modality. Next session: Process behavioral experiment outcome, continue cognitive restructuring for workplace situations, begin assertive communication skill-building. Homework: (1) Complete behavioral experiment - initiate brief conversation with coworker, (2) Continue daily thought records with focus on workplace triggers, (3) Practice diaphragmatic breathing 2x daily. Return in 1 week."
Full Session Note Example
Below is a complete therapy session note example for a client with depression, demonstrating both SOAP and DAP formats documenting the same session.
Individual Therapy Session - Major Depressive Disorder
Scenario: 42-year-old client with MDD, 8th session of individual CBT. Working on behavioral activation and cognitive restructuring. Recently started Sertraline 50mg with psychiatrist.
S - Subjective
O - Objective
Behavior: Good eye contact, smiled appropriately several times, engaged and participatory.
Mood/Affect: "Pretty good" / congruent, brighter affect than previous sessions, full range.
Speech: Normal rate, rhythm, volume; spontaneous.
Thought Process: Linear, goal-directed, no tangentiality.
Thought Content: Residual self-critical cognitions; no delusions, obsessions, or preoccupations.
Insight/Judgment: Good; recognizes improvement and connects to combined treatment approach.
PHQ-9: 8 (mild; decreased from 18 at intake).
Interventions: Reviewed behavioral activation log and reinforced progress. Identified automatic negative thoughts about work performance using thought record. Cognitive restructuring for "I should be perfect" core belief. Introduced concept of self-compassion. Assigned continued behavioral activation with added challenging activity.
A - Assessment
P - Plan
Individual Therapy Session - Major Depressive Disorder
Scenario: 42-year-old client with MDD, 8th session of individual CBT. Working on behavioral activation and cognitive restructuring. Recently started Sertraline 50mg with psychiatrist.
D - Data
Client reported "this was the best week I've had in months," rating mood 7/10 (compared to 3/10 at intake). Attributes improvement to combination of medication and therapy skills. Completed all behavioral activation assignments including gym attendance (twice), social outing with friend, and organizing home office. Stated "I actually wanted to do things this week - that's new." Sleep improved to 7 hours with fewer awakenings; appetite normalizing. PHQ-9 score: 8 (mild severity, decreased from 18 at intake). Denies SI/HI.
Identified ongoing challenge with self-critical thoughts about work performance: "Even when things go well, I find a way to criticize myself." Explored this pattern using thought record technique. Client demonstrated good insight, identifying "I should be perfect" as underlying belief. Cognitive restructuring addressed evidence for/against perfectionism as useful standard. Introduced concept of self-compassion as alternative to self-criticism; client receptive though acknowledged difficulty. Client stated "Being kind to myself feels foreign, but I can see why it matters."
Reviewed behavioral activation progress and reinforced gains. Collaboratively planned continued activation with addition of one "stretch" activity previously avoided. Coordination maintained with prescribing psychiatrist (Dr. Smith); medication well-tolerated.
A - Assessment
P - Plan
This example demonstrates comprehensive session documentation that supports continuity of care, demonstrates medical necessity, and tracks treatment progress.
Tips for Session Documentation
Effective therapy documentation balances thoroughness with efficiency. These best practices will help you write better session notes in less time.
Document Interventions Specifically
Instead of "provided support" or "processed feelings," use specific intervention language: "utilized cognitive restructuring," "employed behavioral activation," "provided psychoeducation on anxiety cycle." This demonstrates skilled service and justifies medical necessity.
Connect Sessions to Treatment Goals
Reference how the session content relates to the client's treatment plan goals. This creates a clear narrative of progress and keeps documentation focused on clinically relevant information.
Use Objective Language for Observations
Write "client appeared tearful" rather than "client was sad." Describe observable behaviors rather than interpretations in your data/observation sections. Save clinical interpretation for the assessment.
Include Client Quotes Sparingly
Direct quotes can be powerful for capturing significant statements, but use them selectively. One or two meaningful quotes per note is sufficient. Paraphrase routine content.
Document Safety Consistently
Include safety assessment in every note, even when denied. "Denies SI/HI" takes seconds to write and demonstrates you consistently assess for safety. When risk is present, document thoroughly.
Write Notes the Same Day
Complete documentation as soon as possible after the session while details are fresh. Notes written days later are less accurate and take longer to complete.
Keep Plans Actionable
Treatment plans should be specific enough that another clinician could follow them if needed. "Continue therapy" is insufficient; "Continue weekly CBT with focus on cognitive restructuring for workplace anxiety" is actionable.
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Frequently Asked Questions
What should be included in a therapy session note?
A therapy session note should include: client presentation (appearance, mood, affect), content discussed during the session, therapeutic interventions used, client's response to interventions, clinical assessment of progress, and the plan for continued treatment. Safety assessments (SI/HI) should be documented when clinically indicated, which for most clients means every session.
What is the difference between SOAP and DAP notes for therapy?
SOAP notes have four sections (Subjective, Objective, Assessment, Plan) that separate client-reported information from clinician observations. DAP notes have three sections (Data, Assessment, Plan) that combine all session information into a single Data section. DAP is more commonly used in mental health settings because the subjective/objective distinction can feel artificial in talk therapy where most data comes from dialogue.
How long should therapy session notes be?
Therapy session notes should be thorough enough to document the essential elements of the session but concise enough to be practical. Most session notes are 150-400 words. The key is to include enough detail to justify medical necessity, track progress toward treatment goals, and provide continuity of care without excessive narrative that no one will read.
Do I need to document every session the same way?
While the format should remain consistent (always use SOAP or always use DAP), the content of each note will vary based on what occurred during the session. Every note should include the core elements (presentation, interventions, assessment, plan), but the depth of each section will depend on the session's content and clinical significance.
How do I document suicidal ideation in session notes?
When documenting SI, include: specific statements made by the client (if they disclosed), presence or absence of plan and means, protective factors identified, risk assessment conducted, interventions implemented (safety planning, crisis resources provided), and follow-up plan. Document that you assessed for SI even when denied, using language like "Client denies SI/HI" or "No SI/HI reported."
What interventions should I document in therapy notes?
Document interventions specifically enough to demonstrate skilled service. Instead of "discussed feelings," write "utilized cognitive restructuring to address catastrophic thinking about job performance." Common interventions include: psychoeducation, cognitive restructuring, behavioral activation, exposure, validation, reflective listening, skill-building (DBT skills, coping strategies), mindfulness techniques, and motivational interviewing.
Can I use AI to help write therapy notes?
Yes, AI documentation tools like SOAP Note Buddy can generate draft session notes that you review and customize. This can significantly reduce documentation time while maintaining quality. The key is to always review and edit AI-generated content to ensure accuracy and clinical appropriateness. AI is a starting point, not a replacement for clinical judgment.
Do insurance companies have specific note requirements?
Most insurance companies accept both SOAP and DAP formats as long as notes contain the essential elements: what the client presented with, what interventions were provided, clinical assessment, and the treatment plan. Some payers may have specific requirements (like SOAP format), so check your contracts. All notes should demonstrate medical necessity for the services provided.