Copy the structure below into the Session Notes field and fill in the brackets. Pick whichever format fits your style or your supervisor's requirements — the Note Type field on each session just tracks which one you used.
SOAP format
S — Subjective
[Client's self-reported mood, concerns, and updates since last session]
O — Objective
[Observable behavior, affect, appearance, engagement level]
A — Assessment
[Clinical impression — progress toward goals, risk factors, diagnostic considerations]
P — Plan
[Next steps, interventions planned, homework assigned, next session focus]
DAP format
D — Data
[What was discussed, observed, and reported — combines subjective and objective]
A — Assessment
[Clinical interpretation of the data — progress, patterns, concerns]
P — Plan
[Next steps and homework for the client, focus for next session]
BIRP format
B — Behavior
[What the client presented with — statements, behaviors, symptoms]
I — Intervention
[What you did in session — techniques, modalities, questions asked]
R — Response
[How the client responded to the intervention]
P — Plan
[Next steps, homework, focus for next session]
Free-form
No fixed structure — useful for intake sessions, crisis sessions, or when a rigid format doesn't fit what needs to be captured. Still worth noting mood/presentation, key themes, and next steps somewhere in the note.
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