Therapy Progress Notes Cheat Sheet: Formats and Free PDFs

• In any format, a payer-ready progress note should contain: the client, date, session time, interventions, client’s response, progress toward goals, the plan, and your signature.¹²
• SimplePractice includes pre-built DAP or SOAP notes as part of its $79 Essential and $99 Plus plans. Its Note Taker add-on aids with drafting notes for $35 a month after a 30-day trial. BRIP, GRIP or PIRP require a custom template.
• You can find free cheat sheets PDFs on Carepatron, as well as from state and county agency documentation guides. SimplePractice offers free format templates.

A progress note is the documentation a mental health professional adds to a client’s chart after each session and progress note cheat sheets help clinicians organize documentation using common formats. The most common formats include SOAP, DAP, BIRP, GIRP, and PIRP. Each format organizes the information a clinician records differently, but the goal is the same: to document the session clearly and consistently.

Do you have to use a specific progress note format? No. Medicare specifies what documentation must include, not which format you have to use. Any of these formats can work as long as the note meets the applicable documentation requirements.³ Also, for Medicare psychotherapy codes 90832, 90834, and 90837, notes must include the session’s start and stop times or total time.¹

SimplePractice, an electronic health record (EHR) platform for private practices, offers templates for these formats, along with AI tools to help draft notes.

Start a 30-day SimplePractice trial with DAP and SOAP templates

This article is for informational purposes only and isn’t medical or legal advice. Documentation requirements vary by state, license, and payer.

ChoosingTherapy.com may earn a commission from the companies whose services are linked on this page.

What Every Progress Note Must Contain

Medicare, Medicaid plans, and county mental health programs have overlapping documentation requirements, although the details vary by payer. Medicare’s billing article A57520 requires client identification, dates on each page, a legible signature, and start and stop times or total time for psychotherapy codes 90832, 90834, and 90837.1 CGS’s coverage policy also addresses the therapeutic techniques used, progress toward treatment goals, and updates to the treatment plan.³ Pennsylvania Medicaid standards from Magellan and California’s Medi-Cal rules include additional requirements, such as place of service, service times, diagnosis and procedure codes, and next steps.²⁴

Taken together, these requirements provide a useful checklist for progress notes:

• Client identification and date: Client name or ID and date of service on each page.
• Session details: Start and stop times or total minutes, service type, and CPT code.
• Diagnosis: The applicable ICD-10 diagnosis.
• Treatment goals: The problem addressed and how it relates to the treatment plan.
• Interventions and response: Techniques used and how the client responded.
• Progress and risk: Progress toward goals, lack of progress, and risk concerns when relevant.
• Plan: Next steps and plans for the next session.
• Signature and credentials: Clinician’s signature and credentials, with any later changes signed and dated.

Some programs have additional requirements. For example, Connecticut’s Department of Mental Health and Addiction Services (DMHAS) requires documentation supporting the level of care based on medical necessity criteria.⁵

How long does a psychotherapy session need to be?

Medicare’s time ranges for these psychotherapy codes are:

• 90832: 16–37 minutes
• 90834: 38–52 minutes
• 90837: 53 minutes or more.¹

For more details on choosing the right code, see our guide to CPT Codes for Psychotherapy.

Progress Note Formats: SOAP, DAP, BIRP, GIRP and PIRP

Each format organizes the same information differently, but some agencies require a specific one. Nevada’s children’s mental health services adopted DAP as its charting model in 2008, while Connecticut DMHAS uses GIRP.⁶⁵ In private practice, your supervisor or EHR templates may determine which format you use.

Table as of October 12, 2026. Some template sites also list PAIP, a less common variant.

SOAP can make it harder to show changes over time, according to StatPearls. To address this, the Assessment section should connect the client’s current presentation to their treatment goals. Our SOAP Notes for Therapy guide covers the format in more detail.

• DAP combines SOAP’s Subjective and Objective sections into one Data section. Nevada’s policy uses this section to capture client quotes, observed mood and affect, session content, homework review, and who attended. Assessment covers the clinician’s analysis and the client’s response to the treatment plan. Plan documents the goals addressed, next steps, and any changes in medical necessity.⁶
• BIRP generally meets Alameda County’s documentation standards, according to its provider manual.⁷ SimplePractice recommends keeping each BIRP section to a few sentences.
• GIRP starts with a goal from the treatment or recovery plan, then documents the interventions used, why they were needed, their intensity and provider, the client’s response, and next steps.⁵ SimplePractice notes that GIRP is less commonly used by therapists than SOAP or DAP.
• PIRP is described by SimplePractice as a problem-focused format that can help document medical necessity.
• SIRP appears in Marin County’s documentation guide, where Situation explains why the session was necessary.⁸

Sample Progress Notes

The following fictional therapy progress notes show how the same documentation checklist can be organized using DAP and BIRP formats. Both examples are for illustration only and are not based on real client records or intended as clinical guidance. Bracketed fields indicate information to fill in.

DAP Progress Note Example

Client: “J.,” fictional adult
Date: [Date]Service: Individual psychotherapy, telehealth
Time: 4:00 p.m.–4:45 p.m. (45 minutes)
CPT Code: 90834
ICD-10 Code: [From treatment plan]

Session 6

D to Data: Client’s father died in March. Client stated, “Sundays are the hardest.” Reports crying most evenings and skipping two family dinners. Completed grief journal on 3 of 7 days. Affect sad and tearful, congruent with session content. Speech soft, with normal rate. Thought process linear.

A to Assessment: Some progress toward Goal 1 (return to weekly contact with family). Explored avoidance of family events and reframed guilt about missing them. Client identified one relative to call. Grief continues to affect sleep and work concentration, supporting continued weekly care. Risk assessed; client denied thoughts of self-harm.

P to Plan: Goal 1, Objective 1a addressed. Homework: call her sister once and continue the grief journal. Continue weekly sessions; next appointment [Date].

Signature: [Clinician, credentials]Date Signed: [Date]

BIRP Progress Note Example

Client: “R.,” fictional adult
Date: [Date]Service: Individual psychotherapy, in person
Time: 10:00 a.m.–11:00 a.m. (60 minutes)
CPT Code: 90837
ICD-10 Code: [From treatment plan]

B to Behavior: Client reports four panic episodes this week, all while driving on the highway. Now takes side roads to work. Affect anxious, brighter when describing a drive completed successfully. Speech initially rapid, then slowed. Thought process linear and goal-directed.

I to Intervention: Explored triggers for panic episodes. Taught paced breathing and practiced it twice during the session. Identified the thought “I’ll lose control of the car” and developed an alternative thought. Assessed risk; client denied thoughts of harming herself or others.

R to Response: Engaged throughout the session. Reported anxiety decreasing from 7/10 at the start to 4/10 after practice. Agreed to complete one short highway drive with a friend. Some progress toward Goal 1.

P to Plan: Continue weekly sessions; next appointment [Date]. Homework: practice breathing daily, complete one supported highway drive, and keep a panic log. Session lasted 60 minutes, within the time range for CPT code 90837.

Signature: [Clinician, credentials]Date Signed: [Date]

Intervention and Affect Word Banks

Finding the right words can take longer than writing the note itself. These quick-reference word banks help clinicians describe interventions and client presentation more clearly and consistently. They draw on a county documentation guide, a peer-reviewed reference on the mental status exam, and Medicare coverage policies.

The intervention verbs and anxiety-related phrases come from Marin County’s documentation guide. The techniques reflect what CGS and Novitas say psychotherapy notes should document.⁸³

StatPearls recommends recording mood in the client’s own words, using quotation marks, and describing affect based on the clinician’s observations of the client’s expression. Notes should also indicate whether mood and affect are congruent. Affect alone, should not be used to make a diagnosis.⁹

A few habits can make progress notes faster to write. Clinicians often start with the previous note, use a consistent template, save commonly used phrases, and keep a checklist of interventions. Some report getting notes done in 3–5 minutes this way. The goal is to document enough to support medical necessity without adding unnecessary detail, consistent with the NASW Code of Ethics’ emphasis on recording information relevant to professional services.

Progress Notes vs. Psychotherapy Notes: What Goes Where Under HIPAA

The information on your progress note checklist belongs in the clinical record. It does not qualify for HIPAA’s separate protections for psychotherapy notes.

Under 45 CFR 164.501, psychotherapy notes are a therapist’s notes documenting or analyzing the contents of a counseling conversation, kept separate from the rest of the medical record. The definition specifically excludes session start and stop times, treatment modalities and their frequency, medication prescriptions and monitoring, test results, and summaries of diagnosis, functional status, treatment plans, symptoms, prognosis, or progress.¹⁰

In practice, session times, interventions, assessment scores, treatment goals, and progress belong in the clinical record. A therapist’s separate notes analyzing what was said during a session may qualify as psychotherapy notes if they meet HIPAA’s definition and are kept apart from the record. CMS explains that combining the two does not give ordinary clinical documentation the extra protection afforded to psychotherapy notes. Alameda County likewise warns that psychotherapy notes filed with the clinical record lose that special protection.¹¹⁷

Can clients access their progress notes? Generally, yes. Under 45 CFR 164.524, clients have a right to access their medical records, including progress notes, while qualifying psychotherapy notes are excluded from that right of access.¹²

Medicare reviewers may not request separately maintained psychotherapy notes, but providers still need sufficient clinical documentation to establish medical necessity for billed services. Missing or inadequate documentation can result in a claim denial.¹¹

SimplePractice offers a separate psychotherapy notes feature across all three of its plans, keeping those notes separate from the clinical record.

Compare SimplePractice plans and note templates

How Soon Are Progress Notes Due?

There’s no single federal deadline requiring private practice therapists to complete progress notes within 24, 48, or 72 hours. Specific deadlines often come from state and county programs.

Here are some examples:

• California Medi-Cal: Within 3 business days, or 24 hours for crisis services.⁴
• Alameda County: Within one working day. Late notes must be identified as late entries.⁷
• Marin County: Same day when possible, with notes finalized within 72 hours or 3 business days and marked “late entry” when applicable. The guide also considers timeliness over time.⁸
• Nevada DCFS children’s services: By noon on the Tuesday following the week of service.⁶

Professional ethics guidelines also emphasize timely documentation. The APA’s 2007 record-keeping guidelines, archived in 2019, recommend making entries as soon as practicable. The ACA and NASW ethics codes similarly call for timely records. Medicare expects services to be documented when they’re provided, and late entries must identify the date and author.¹¹

Where to Get a Free Therapy Progress Note Cheat Sheet PDF

You can find free progress note templates and cheat sheets from EHR companies and public mental health agencies. Professional association training materials may cost extra. For example, NASW North Dakota’s 2024 documentation training, which included two note templates, cost $33 for members.

The following resources were available as of October 12, 2026:

• SimplePractice: Free SOAP, DAP, BIRP, GIRP, and PIRP templates through its how-to guides, with worked examples. The BIRP download requires submitting an email form.
• Carepatron: A free six-page progress note cheat sheet PDF with phrase banks for observations, emotional state, goals, interventions, responses, and homework, plus a completed sample.
• Connecticut DMHAS: A one-page GIRP tip sheet published in 2021.⁵
• Nevada DCFS: A three-page DAP policy from 2008.⁶
• Marin County: An 86-page documentation guide from 2018 that includes intervention word lists.⁸
• Alameda County: An undated documentation manual covering BIRP.⁷

EHR Templates and AI Note Tools

An EHR template turns a cheat sheet into a reusable form, with the same fields ready to fill in after each session. Some platforms also offer AI tools that draft progress notes for you. Here’s how the options compare, including pricing and available features checked in September and October 2026.

SimplePractice

SimplePractice costs $49 per month for Starter, $79 for Essential, and $99 for Plus. According to its support pages, Starter includes intake forms and scored measures, while prebuilt progress note templates start with Essential. Essential and Plus also let you customize templates. BIRP, GIRP, and PIRP templates aren’t included by default, but you can create your own. Find them under Settings > Documentation > Template Library.

SimplePractice’s Note Taker transcribes sessions without storing a recording, then drafts a note based on the format used in the client’s previous note. You review and edit the draft before saving. The Essential plan with Note Taker costs $114 per month. Recording and transcription consent requirements vary by state; Illinois, for example, requires written client consent for AI note support involving recorded or transcribed sessions.

As of October 12, 2026, new customers who start a paid plan within the first seven days of the trial can get 50% off for four months through our link. The discount doesn’t cover the $20 annual AMA CPT code fee per clinician. For a closer look at its other features, read our SimplePractice Review.

Other EHRs

Other EHR platforms offer different ways to create and manage progress notes:

• Practice Better: Includes BIRP among its built-in note formats.
• Jane: Offers a template library built from templates shared by clinics, which you can edit.
• Healthie: Offers one-click group charting and automatically scored PHQ-9 forms.
• TherapyNotes: Provides a template library that practice administrators can enable.

Our SimplePractice Alternatives guide compares these EHR platforms side by side.

Try SimplePractice Free for 30 Days