SOAP, DAP & BIRP Therapy Note Templates

What each therapy notes format asks for:

• SOAP (Subjective, Objective, Assessment, Plan): the client's report in S, your observations in O, your synthesis in A, next steps in P. The most widely recognized format and the one most EHR note templates default to.
• DAP (Data, Assessment, Plan): a SOAP note with S and O merged into one Data section. Faster to write when the report and the observation are hard to keep apart, and the format many agencies teach first.
• BIRP (Behavior, Intervention, Response, Plan): the I and R sections name the technique you used and what the client did with it. Agencies that track interventions tend to require it.

Whichever you use, the same two rules apply. Symptoms the client reports and signs you observe stay separate from your interpretation, and the plan says what happens before and at the next session. Every template in this pack is built around those rules.

• The same structure every time. Notes get read next to the treatment plan by supervisors and, sometimes, payer reviewers. The same sections in the same order, session after session, is what makes them easy to follow.
• Specifics every session. Each section is a form field that asks for this session's content: today's report, today's observation, today's plan. That is what keeps a note from reading like last week's.
• Guidance that stays out of the note. A short note on what belongs in each section, and the weak version to avoid, shows while you write and is never inserted.
• Details that follow from other details. Type the minutes the session actually ran and the CPT code fills in (90832, 90834 or 90837, and no psychotherapy code under 16 minutes). Check it against your payer's rules before you bill.
• Editable output. The note lands as text in whatever field you are in, so you can change anything before you sign. The SOAP header lands as a small table in rich-text fields and as plain lines in plain-text fields.
• In your keyboard, not in a PDF. A cheat sheet you print still means retyping the headings. A template you insert with a shortcut types them for you.

If your EHR's note template works for you, keep it. This pack is for the places it does not reach: the portal message, the supervision summary, the Google Doc, a second EHR at a group practice, and the sentences you type inside any template.

If you use an AI scribe, the two work together. The scribe drafts the narrative. The skeleton is where that draft goes, in the format your payer expects, and the one-line snippets are the parts you type yourself: the screening sentence, the plan closer, the homework line.

Inside the pop-up

Clinician, date of service and session minutes at the top, with your name saved once. The minutes field starts as a [minutes] prompt, not a number, so you type the time this session actually ran. The CPT code follows from it: 16 to 37 minutes reads 90832, 38 to 52 reads 90834, 53 or more reads 90837, and under 16 minutes gets no psychotherapy code. Until you type a number the line reads CPT [type the minutes], and a note says to check the code against your payer. Then S as a paragraph field for what the client reported, in their words. O opens with an affect menu (euthymic, anxious, depressed, flat, irritable) and an engagement menu (engaged, variably engaged, guarded), then "oriented ×4" and a field for other observable signs. A and P are paragraph fields, and a signature line closes the note. A guidance note about keeping S, O and A distinct shows while you write and never lands in the note.

Filled in for a fictional client, it reads:

Clinician: Alice Smith, LPC · Date: 2026-08-24 · 45 min · CPT 90834
S: Client reports two panic episodes this week, both on workday mornings, and says the breathing practice "actually helped once I remembered it."
O: Affect anxious, engaged, oriented ×4. Restless early, settled.
A: Panic symptoms are down from baseline four episodes weekly to two, and client is applying the interoceptive strategies with partial success, consistent with goal 1 progress.
P: Continue weekly sessions. Homework is one interoceptive exposure with the log. Revisit workplace triggers next session.
Signed, Alice Smith, LPC

Your name, the section labels, "oriented ×4" and the signature were already typed, and the CPT code followed from the 45 minutes. The rest is this session's words.

The other note templates

• /dap: a presentation menu, a Data paragraph, an interventions menu you can pick several from, a client response menu with an optional detail line, then A and P.
• /birp: a Behavior paragraph, a techniques menu with a field for how you applied it, a client response menu with a detail field, and a Plan line.
• /ros, the psych review of systems, for prescribers and intake evaluations: a lead menu, toggles for mood, sleep, appetite and concentration that add a line each, an SI/HI screen menu and an optional risk note.
• /hpi, the history of present illness opener, for evaluations and psychiatric notes: the presenting concern, course and severity menus, and toggles for prior treatment and current medications.
• /plan, /sum and /fu: the closing Plan paragraph, a two-sentence session summary, and a follow-up contact note for between-session calls and messages.
• /goal, the SMART goal builder: behavior, measure, timeframe and baseline fields, a review-interval menu and a barriers toggle, so the goal reads the same in the note and in the treatment plan.

One-line snippets for the sentences you type most

• /arrived, the session opener: on time, appropriately groomed, engaged throughout.
• /o.wnl, the objective line for an unremarkable session: affect, speech, thought process, orientation.
• /denies.sihi, the SI/HI screening sentence.
• /technique, an intervention sentence with the technique picked from a menu.
• /responded, the client response line for an engaged session.
• /progress, the assessment line that ties the session to the treatment plan.
• /homework, the homework sentence with one field for the assignment.
• /nextweek, the plan closer for a routine weekly session.

Same shape every time, this session's words in every field: consistent structure with specific content is what reads well in an audit.