SOAP Note Example & Template for Therapists (+ DAP, BIRP)
Written by Kshitij Domadia, Founder, MyKaya
Published July 9, 2026
If you write therapy notes by hand after each session, you already know this format — even if you never learned the acronym. SOAP, DAP, and BIRP are the three structures that cover the majority of outpatient mental health documentation. Each one is designed to answer the same question: "What happened in this session, what did I do about it, and what's the plan?" They just answer it in slightly different ways.
This page gives you a real example of each format, a copyable template, and a plain-English explanation of when each one is the right call.
Before you copy-paste: Your licensing board, employer, or payer may specify which format they require. When in doubt, check before switching.
SOAP notes
Stands for: Subjective — Objective — Assessment — Plan
SOAP is the standard in most medical and integrated care settings. The key distinction is the split between S (what the client reports) and O (what you observe). That separation is deliberate: it keeps the client's words distinct from your clinical judgment, which matters for both accuracy and liability.
When to use it: You work in a hospital, integrated care, or multidisciplinary team setting. Your documentation may be reviewed by physicians or other medical providers. Your payer requires it.
SOAP note example
Date: 2026-07-09
Client: Adult, Generalized Anxiety Disorder (GAD), session 14
Session length: 50 minutes
S (Subjective): Client reports that anxiety has been "a 7 or 8 out of 10" this week, primarily related to a performance review at work. States she has been waking at 3 a.m. and unable to return to sleep. "I know it's probably fine, but I can't stop running the worst-case scenarios." Denies low mood, passive ideation, or changes in appetite.
O (Objective): Client arrived on time, appeared tense, maintained intermittent eye contact. Speech rate was faster than baseline. No psychomotor agitation. No evidence of dissociation or thought disorder. PHQ-9 completed: score 6 (mild, unchanged from last session). GAD-7: score 12 (moderate, up from 9 at session 12).
A (Assessment): Client is experiencing an acute exacerbation of GAD in the context of occupational stressor. Sleep disruption and ruminative thought patterns are consistent with prior presentation. GAD-7 increase (9→12) warrants continued monitoring. No safety concerns identified.
P (Plan): Continue CBT, focusing on cognitive restructuring of catastrophic appraisal patterns. Introduced progressive muscle relaxation for sleep onset. Client to practice stimulus control technique for 3 a.m. waking. Discussed sleep hygiene briefly. Next session in one week. Will re-score GAD-7 at session 16 to track response.
SOAP template
Date:
Client description (no name in notes):
Session length:
S (Subjective): [Client's reported symptoms, quotes, self-assessment of mood, relevant history from client's perspective]
O (Objective): [Your observations: presentation, affect, behavior, psychomotor activity, completed screeners and scores]
A (Assessment): [Clinical interpretation: diagnosis status, progress, risk level, relevant patterns or changes from prior sessions]
P (Plan): [Interventions used, skills assigned, referrals made, next session date, any follow-up items]
DAP notes
Stands for: Data — Assessment — Plan
DAP combines the S and O sections from SOAP into a single Data section. It is faster to write and works well when the subjective/objective distinction feels artificial for your session (which it often does in talk therapy). Most outpatient private-practice settings accept DAP or prefer it.
When to use it: You are in outpatient private practice or community mental health. Sessions are primarily talk-based. You want efficient documentation without a prescribed clinical structure.
DAP note example
Date: 2026-07-09
Client: Adult, Major Depressive Disorder (MDD), session 7
Session length: 50 minutes
D (Data): Client arrived 5 minutes late, appearing fatigued. Reported "a rough week — I slept a lot but still felt exhausted." Discussed conflict with partner around household responsibilities; described feeling "invisible and unimportant." Mood described as 4/10. Brighter affect emerged mid-session when discussing a positive interaction with a colleague. No safety concerns reported or observed; C-SSRS passive ideation question answered negatively.
A (Assessment): Client continues to demonstrate depressive symptoms consistent with MDD, with interpersonal stressors as a key maintaining factor. Emotional reactivity (shift in affect when discussing positive interaction) suggests responsiveness to social reinforcement, which may be a useful lever in treatment. Sleep pattern warrants ongoing attention — hypersomnia is present despite subjective fatigue.
P (Plan): Explored behavioral activation strategies targeting interpersonal connection. Client agreed to initiate one social plan before next session. Discussed sleep hygiene in context of depressive sleep pattern. Next session in one week. Will administer PHQ-9 at session 8 (due for scheduled re-score).
DAP template
Date:
Client description:
Session length:
D (Data): [All factual information from the session — what the client reported, how they presented, screener scores, any significant events]
A (Assessment): [Your clinical interpretation — diagnosis status, progress against goals, risk, any notable patterns or changes]
P (Plan): [Skills practiced, interventions used, homework assigned, referrals, next session date, any follow-up items]
BIRP notes
Stands for: Behavior — Intervention — Response — Plan
BIRP puts the therapist's specific actions and the client's direct response at the center of the note. It is the format most commonly used when you need to demonstrate medical necessity for billing — because it makes it explicit what you did and whether it worked. It is also useful for supervision contexts.
When to use it: You bill insurance. You need to document specific interventions for medical necessity. You work in a behavioral health or substance use setting. You are under supervision and need to demonstrate technique.
BIRP note example
Date: 2026-07-09
Client: Adult, PTSD, session 19
Session length: 50 minutes
B (Behavior): Client presented with constricted affect and described experiencing two intrusive images during the week, both linked to the identified traumatic event. Reported avoidance of driving on the highway again this week. Sleep continuity disruption persists (waking 2–3 times per night). Denied suicidal ideation. PHQ-9: score 11 (moderate, stable from session 17).
I (Intervention): Conducted prolonged exposure protocol, Phase 3 (imaginal exposure). Therapist guided client through a 20-minute imaginal revisiting of the traumatic memory, including calm processing questions following the exposure. Psychoeducation provided on avoidance maintenance cycle and the role of approach behavior in PTSD recovery.
R (Response): Client's subjective units of distress (SUDS) began at 8/10 and reduced to 4/10 by end of imaginal exposure. Client identified "I survived it and I'm still here" as a meaningful adaptive cognition. Verbalized understanding of avoidance cycle; expressed ambivalence about the highway driving exposure but agreed to attempt a partial approach this week.
P (Plan): In vivo exposure homework assigned: drive on highway on-ramp (not full highway) once before next session. Review SUDS log at session 20. Continue imaginal exposure. Monitor sleep. Next session in one week.
BIRP template
Date:
Client description:
Session length:
B (Behavior): [Observable behavior, mood, client-reported concerns, screener scores]
I (Intervention): [Specific techniques the therapist used — be explicit: named protocol, psychoeducation, skill instruction, etc.]
R (Response): [How the client reacted — engagement, resistance, insight, SUDS, verbal responses, behavioral shift during session]
P (Plan): [Homework, next steps, follow-up, next session date]
Quick comparison
| SOAP | DAP | BIRP | |
|---|---|---|---|
| Best setting | Medical, integrated, multidisciplinary | Outpatient private practice | Insurance billing, behavioral health |
| Distinguishes S/O? | Yes | No (combined into Data) | No (Behavior covers both) |
| Shows what therapist did? | Partially (in Plan) | Partially (in Plan) | Yes — Intervention section |
| Shows client's response? | Partially | Partially | Yes — Response section |
| Speed to write | Moderate | Fast | Moderate |
A note on clinical screeners
Whichever format you use, screener scores (PHQ-9, GAD-7, C-SSRS) should appear somewhere in your note — either in the O or Data section. Do not leave them in a separate system and assume someone will connect the dots. If you are using MyKaya, standardized screeners live in a dedicated section of each client's profile, separate from the session note, so your documentation stays clean and your risk tracking stays visible across sessions.
Or: let the note write itself
Writing a good SOAP or DAP note by hand takes most therapists 10–20 minutes per session. MyKaya generates the full clinical note from session audio in the format you use — SOAP, DAP, BIRP, and 20+ others. You review and sign. The 3 a.m. note writing stops being your problem.