Therapy Progress Notes Cheat Sheet

This therapy progress notes cheat sheet fits the essentials on one printable page: the five most common note formats and their sections, the elements every progress note needs, clinical words for interventions, client responses and affect, and the mistakes reviewers flag most. Keep it beside you while you write, or print it for new clinicians and trainees.

Tip: choose "Save as PDF" in the print dialog to keep a copy.

Last updated: October 6, 2026

Which note format has which sections?

Format	Sections	Common in
SOAP	Subjective, Objective, Assessment, Plan	Most settings; integrated and medical teams
DAP	Data, Assessment, Plan	Outpatient counseling, quick notes
BIRP	Behavior, Intervention, Response, Plan	Behavioral health agencies
GIRP	Goal, Intervention, Response, Plan	Goal-driven treatment plans
PIE	Problem, Intervention, Evaluation	Social work and case management

What must every progress note include?

Client identifier, date, start and stop time, service type and location (or telehealth)
Why the client was seen: presenting concern or treatment goal addressed
What you did: named interventions, not "provided support"
How the client responded, with observable detail or a score
Risk: what you screened for and the result, with any safety steps
Progress toward treatment plan goals
Plan: next session focus, homework, referrals, next appointment
Your signature and credentials, completed within your required timeline

What do reviewers flag most often?

Copy-forward notes with the same wording every week
Opinions without observations ("client was manipulative")
Interventions with no client response
No link to a treatment plan goal
Missing or rounded session times
Risk mentioned in session but not documented
Private process analysis written into the progress note

Intervention words

Pair each verb with a named technique and a target: "Reframed catastrophic predictions using a thought record."

Explored
Processed
Validated
Reflected
Reframed
Challenged
Modeled
Role-played
Rehearsed
Taught
Provided psychoeducation on
Assigned
Reviewed
Facilitated
Assessed
Monitored

Client response words

Prefer what you observed or measured: "Rated anxiety 4/10, down from 7."

Identified
Demonstrated
Verbalized
Rated
Completed
Practiced
Agreed to
Declined
Was receptive to
Was unable to
Became tearful when
Reported
Initiated
Generated

Words for mood and affect

Mood is what the client reports, in their words. Affect is what you observe.

Euthymic
Anxious
Dysphoric
Irritable
Restricted
Flat
Labile
Congruent with content
Tearful
Guarded
Engaged
Cooperative

How do you write one strong sentence?

Technique + target + goal + response.

"Used behavioral activation (scheduled 3 valued activities) targeting withdrawal (Goal 1). Client agreed to two morning walks and identified one barrier."

Keep private process analysis out of the progress note. Under HIPAA, summaries of diagnosis, symptoms, treatment plan and progress always belong in the record, not in separate psychotherapy notes.

Where can you go deeper?

Therapeutic interventions list with example wording for CBT, DBT, MI, psychodynamic, solution-focused and ABA work.
Therapy progress notes examples and templates with full SOAP, DAP and BIRP notes for different scenarios.
Process notes vs progress notes under HIPAA.
The printable SOAP note template and the full library of clinical note templates.

Frequently asked questions

What should every therapy progress note include?

Client identifier, date and session times, the concern or goal addressed, named interventions, the client response, risk screening and result, progress toward treatment goals, the plan, and your signature and credentials.

Is there a PDF version of this cheat sheet?

This page is designed to print on one or two pages. Use the Print button or your browser print command, and choose Save as PDF if you want a file to keep.

Which progress note format should I use?

Use the format your agency, payer or supervisor requires. Without a requirement, SOAP is the most widely recognized, DAP is faster to write, and BIRP or GIRP suit settings that track interventions and goals closely.

What is the difference between progress notes and psychotherapy notes?

Progress notes are the clinical record of the session. Psychotherapy notes, sometimes called process notes, are a therapist separate notes analyzing the session conversation. Under HIPAA they cannot contain summaries of diagnosis, symptoms, treatment plan or progress, which belong in the progress note.

Draft the session note from your summary

Type or dictate a short summary after the session, choose SOAP, DAP, BIRP or another format, and WellNotes drafts the note for you to review. Try one de-identified note free with the progress note generator.

Try the free progress note generator