Mental health clinicians document sessions in one of a few standard formats. The format you choose shapes how readable your notes are, how fast you can write them, and how easily a colleague, supervisor, or insurance reviewer can follow your clinical reasoning.
This guide explains the four most common therapy note formats — SOAP, DAP, BIRP, and GIRP — with section-by-section guidance on how to write each, when to use which, and the documentation mistakes that most often cost clinicians time.
Start Free TrialA therapy note format is a structured template that organizes a clinical note into named sections. Instead of writing freeform paragraphs, the clinician fits the session content into predictable slots — what the client said, what the clinician observed, what the clinician interpreted, and what comes next.
A consistent format does three things at once. It makes documentation faster because you're never deciding how to organize the note. It makes the chart reviewable because anyone reading it knows where to find the relevant clinical information. And it improves defensibility — for insurance, audits, and continuity of care — by ensuring each note demonstrates medical necessity, intervention, and outcome.
All of the formats covered here capture similar clinical content. The difference is in how that content is grouped.
Most clinicians choose between four formats. SOAP and DAP are the most widely used overall; BIRP is more common in behavioral health; GIRP is most often seen in goal-driven treatment-planning workflows.
| Format | Sections | Best For | Writing Speed |
|---|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | Structured clinical environments | Moderate |
| DAP | Data, Assessment, Plan | Concise, fast documentation | Fast |
| BIRP | Behavior, Intervention, Response, Plan | Behavioral health, intervention tracking | Moderate |
| GIRP | Goal, Intervention, Response, Plan | Goal-driven treatment planning | Moderate |
Compare side-by-side: SOAP vs DAP · BIRP vs DAP
SOAP is the most structured of the four formats. Its strength is keeping client report and clinician observation in separate sections, which makes it easy for a reader to distinguish what was said from what was seen.
Subjective
What the client reports — symptoms, mood, life events, and concerns. Use the client's own language where possible. This is the only section where direct quotes are common.
Objective
What you observe or measure — affect, behavior, mental status exam findings, screener scores, attendance. Verifiable, not interpreted.
Assessment
Your clinical interpretation — diagnosis, progress toward goals, risk assessment, formulation. This is where you connect the dots between Subjective and Objective.
Plan
What happens next — interventions used in session, homework assigned, frequency of follow-up, referrals, and any treatment plan adjustments.
When SOAP fits best: structured clinical environments, group practices, settings where multiple providers review the same chart, and any context where separating client report from clinician observation matters for liability or coordination of care.
SOAP Notes (Complete Pillar Guide)
Full SOAP guide — what it is, how to write each section, side-by-side example, and common mistakes.
SOAP Notes Guide
Section-by-section walkthrough with examples and common pitfalls.
SOAP Notes Template
A reusable SOAP template for therapy sessions.
SOAP Note Example
A full SOAP note from a realistic therapy session.
DAP is essentially SOAP with the first two sections collapsed into one. Subjective and Objective become a single "Data" section. Many therapists prefer DAP because writing the data section as a flowing paragraph is faster than separating client report from observation line by line.
Data
The combined picture of the session — what the client reported, what you observed, mental status findings, and any measurable data. Written as one cohesive section rather than split into two.
Assessment
Clinical interpretation, progress, risk, formulation. Same role as in SOAP.
Plan
Interventions delivered, homework, follow-up cadence, and treatment plan changes.
When DAP fits best: high-volume caseloads, counselors and therapists who write notes in narrative flow, and practices where speed of documentation is the priority. DAP keeps the same clinical rigor as SOAP — it just removes one structural boundary.
BIRP reorganizes the note around the intervention–response cycle. Instead of separating data and interpretation, BIRP foregrounds what the clinician did and how the client responded. It's the format of choice in behavioral health, substance-use, and any setting where tracking treatment effectiveness session-by-session matters.
Behavior
The client's presentation in this session — observable behavior, affect, what they reported, and current symptoms. Combines what SOAP would split into Subjective and Objective.
Intervention
What you did clinically — techniques used, modality applied (CBT, motivational interviewing, exposure, etc.), and the rationale. Name interventions specifically rather than describing them generically.
Response
How the client responded to each intervention — emotionally, cognitively, behaviorally. This section is what makes BIRP useful for tracking treatment effectiveness over time.
Plan
Next steps, homework, frequency of follow-up, and any treatment plan adjustments based on the Response section.
When BIRP fits best: behavioral health, substance use, intensive outpatient programs, and any setting where the chart needs to demonstrate which interventions are working. BIRP makes "what we tried, how it went" easy to scan across sessions.
GIRP is the least common of the four but useful in goal-driven treatment workflows. It opens each note with the specific treatment goal addressed in the session, which keeps the chart tied to the broader treatment plan and makes progress tracking easier across sessions.
Goal
The specific treatment plan goal addressed in this session. Pulled from the active treatment plan, written so the link is explicit.
Intervention
What you did to work toward the goal — techniques, modality, and clinical rationale.
Response
How the client responded, including any movement (or lack of movement) toward the goal stated above.
Plan
Next steps for this goal — including whether the goal needs adjustment, escalation, or is ready to close.
When GIRP fits best: case management, agency settings with formal treatment plans, and any context where each session note must demonstrate progress against named goals. GIRP is structurally similar to BIRP but trades Behavior for Goal at the top.
The decision is rarely about clinical content — all four formats capture similar information. It comes down to setting, workflow, and what you're trying to make easy to find later.
Pick SOAP if…
You're in a structured clinical environment, charts are reviewed by multiple providers, or your supervisor or insurance reviewer expects clear separation of client report from clinician observation.
Pick DAP if…
You write notes in flowing prose, you carry a high caseload, and you want the fastest path from session to finished note without losing clinical rigor.
Pick BIRP if…
You work in behavioral health or substance use, your chart needs to show what interventions are working, or you want session-by-session response tracking baked into the format.
Pick GIRP if…
Treatment is organized around explicit goals and each session needs to tie back to the treatment plan — common in agency and case management settings.
Consistency matters more than the choice itself. Pick one format and stay with it inside a given client's chart — switching mid-treatment makes the record harder to review.
These show up regardless of which format you use, and they're the most common reasons notes get flagged in audits or send insurance reviewers asking for clarification.
Naming a modality but not the specific intervention. Writing 'used CBT' is weaker than 'used Socratic questioning to test the client's catastrophizing thought about Friday's meeting.'
Letting the Plan section drift to generic. 'Continue therapy' is not a plan. Concrete next steps, homework assigned, and follow-up cadence belong here.
Mixing observation and interpretation. Saying 'client was anxious' interprets — saying 'client reported racing thoughts; observed pacing and hand-wringing' separates observation from inference.
Skipping risk assessment when clinically indicated. Even a brief 'denied SI/HI; no acute safety concerns identified' is better than silence on the topic.
Writing notes days later. Memory degrades fast. The single highest-leverage habit is writing notes within 24 hours, ideally same day.
Letting note length drift up over time. Longer is not better. Most reviewable notes land between 150 and 400 words.
Failing to connect session content to treatment goals. A reader should be able to see how this session ties back to the treatment plan.
AfterSession generates SOAP, DAP, BIRP, and progress notes from a short session summary — no full session recording required. Clinicians edit and approve every note before it's saved.
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A SOAP note is a structured clinical documentation format with four sections: Subjective (what the client reports), Objective (what the clinician observes or measures), Assessment (clinical interpretation and diagnosis), and Plan (next steps and treatment direction). SOAP is the most widely used note format across mental and physical health settings because it cleanly separates client-reported information from clinician observation.
SOAP separates Subjective and Objective into two sections, giving the most structure. DAP collapses both into a single Data section, which is faster to write. BIRP shifts the focus to Behavior and the Intervention–Response cycle, which is well-suited for behavioral health and progress tracking. All three end with a Plan section. Clinical content is similar across formats — the difference is how it's organized.
Match the format to your setting. SOAP works well in structured clinical environments and group practices where consistency across charts matters. DAP suits high-volume caseloads where writing speed is the priority. BIRP fits behavioral health and substance-use settings where intervention tracking is central. GIRP is useful when treatment planning is goal-driven and you want each note to tie back to client goals. Most clinicians pick one and stay consistent within a client's record.
Most therapy notes are 150–400 words. Length should match clinical complexity: routine sessions can be brief, while high-risk presentations, intake sessions, and significant clinical changes warrant more detail. Overly long notes don't improve care and increase documentation burden; overly short notes may not demonstrate medical necessity for insurance.
The format itself is not what makes documentation HIPAA-compliant. Compliance depends on how notes are stored, who has access, encryption, audit logging, and how protected health information is handled across systems. Any of these formats can be HIPAA-compliant when used inside a compliant EHR or platform.
Yes, but consistency within a single client's record is generally preferred. Some clinicians use different formats for different session types — for example, BIRP for behavioral health groups and DAP for individual sessions — but switching mid-treatment for the same client makes the chart harder to review. Most insurance reviewers, supervisors, and auditors accept any structured format.
Yes. Modern AI therapy note tools like AfterSession can generate SOAP, DAP, BIRP, and progress notes from a brief session summary or transcript, while keeping the clinician in full control of the final note. The format choice is configurable per session.
Generate SOAP, DAP, BIRP, or progress notes in minutes — no session recording required. Full clinician control of every note.