Mental Health Progress Notes Template Bundle for Clinicians: SOAP, BIRP, DAP, GIRP (PDF & Word Docs)

Progress notes are the clinical record of every therapy session — and the format clinicians use to document those sessions shapes how clearly their clinical thinking is captured, how well their records hold up under insurance audit, and how efficiently they can move from session to session without sacrificing documentation quality. Our Mental Health Progress Notes Template Bundle gives clinicians all four of the most widely used structured progress note formats in a single package: SOAP, DAP, BIRP, and GIRP — each built to the same comprehensive clinical standard, available as both editable Word documents and fillable PDFs.

Whether you work in private practice, community mental health, a behavioral health agency, a substance use treatment program, or a training clinic, this bundle provides a complete documentation toolkit that covers every clinical setting and documentation requirement you are likely to encounter across your career.

What Is Included in Our Progress Notes Bundle

Our bundle includes four complete, professionally designed progress note templates:

Comprehensive SOAP Note Template

Organized into Subjective, Objective, Assessment, and Plan sections, our SOAP note template is the most comprehensive of the four and is particularly well suited to settings requiring clear separation of client self-report from clinician observations. It includes:

• Subjective section — patient overview, chief complaint, history of present illness, current symptoms and distress rating, current stressors, medications and allergies, medical and surgical history, family history, social history, and review of systems checklist
• Objective section — behavioral observations, full 14-component Mental Status Examination, standardized assessment results table, interventions provided checkboxes, and client response to interventions
• Assessment section — DSM-5-TR diagnosis table with ICD-10-CM codes and specifiers, structured risk assessment matrix (SI, HI, self-harm, substance use, and other safety concerns), protective factors, risk mitigation actions, and clinical summary and formulation
• Plan section — treatment modality checkboxes, treatment plan by problem, education provided, follow-up and progress monitoring, homework and between-session tasks, referrals, next appointment, final notes, and clinician signature with supervisor countersignature line

Comprehensive DAP Note Template

Organized into Data, Assessment, and Plan sections, our DAP note template consolidates client self-report and clinician observations into a single Data section — a faster format without sacrificing clinical completeness. It includes:

• Data section — session overview, session narrative, current symptoms and functional impairment, stressors, social and life changes, medical and psychiatric updates, treatment goals addressed, and symptom review checklist
• Assessment section — full 14-component Mental Status Examination, standardized assessment results, DSM-5-TR diagnosis with ICD-10-CM code, structured risk assessment matrix, protective factors, risk mitigation actions, and clinical summary and formulation
• Plan section — treatment modality, interventions provided, client response to interventions, education provided, planned actions for future sessions, homework, medical necessity statement, referrals, next appointment, and clinician signature

Comprehensive BIRP Note Template

Organized into Behavior, Intervention, Response, and Plan sections, our BIRP note template is built around the therapeutic process and is particularly strong in behavioral health agencies, community mental health, and managed care settings that require explicit intervention and response documentation. It includes:

• Behavior section — session overview, diagnosis, behavioral observations, full 14-component MSE, standardized assessments, current symptoms and stressors, medication and substance use updates, structured risk assessment matrix, treatment goals addressed, and symptom review checklist
• Intervention section — treatment modality checkboxes, specific interventions provided, primary focus of session, intervention narrative with clinical rationale, and psychoeducation provided
• Response section — client response checkboxes, progress since last session by treatment goal, clinical observations, and session narrative
• Plan section — planned interventions, homework, medical necessity statement, referrals, next appointment, and clinician signature with supervisor countersignature line

Comprehensive GIRP Note Template

Organized into Goal, Intervention, Response, and Plan sections, our GIRP note template is the most treatment-plan-aligned of the four and is particularly well suited to community mental health, publicly funded behavioral health programs, and SAPC settings where notes are reviewed against formal treatment plan goals. It includes:

• Goal section — session overview, primary goal and treatment plan goal number, treatment plan date and review due date, current goal status, treatment goals and measurable objectives table with goal completion ratings (0–100%), factors affecting goal progress checkboxes, and diagnosis with ICD-10-CM code
• Intervention section — treatment modality checkboxes, specific interventions with clinical rationale tied to goals, and psychoeducation provided
• Response section — organized under Clinical Status (MSE, standardized assessments, symptoms, stressors, medication updates), Safety (risk assessment matrix, protective factors, mitigation actions), and Response to Treatment (client response, response relative to goal, goal completion rating, clinical observations, session narrative)
• Plan section — planned interventions, treatment goals for next session with objective and expected timeline, homework, treatment plan status, medical necessity statement, referrals, next appointment, and clinician signature

How Our Bundle Is Used in Practice

Our four-template bundle is designed to serve clinicians across every stage of their career and every clinical setting they work in:

• Private practice — clinicians can select the format that best fits their documentation style, payer requirements, and clinical approach — and switch between formats as their caseload or practice context changes
• Community mental health and agency settings — our BIRP and GIRP templates are built to meet the explicit intervention documentation and treatment plan alignment requirements most common in publicly funded behavioral health settings
• Training clinics and supervised practice — having all four formats in a single bundle allows supervisors to introduce each format and help supervisees develop documentation competency across the full range of progress note structures used in the field
• Multi-clinician practices — practices can standardize documentation across all clinicians by selecting the format that best fits the setting and providing the same template to every provider
• Insurance authorization and audit support — all four templates are structured to explicitly document medical necessity, functional impairment, specific interventions, and client response — the elements managed care organizations and Medicaid programs review most closely

Practice Benefits

• All four of the most widely used structured progress note formats in a single bundle — SOAP, DAP, BIRP, and GIRP — each built to the same comprehensive clinical standard
• Every template includes the full 14-component Mental Status Examination, structured risk assessment matrix, DSM-5-TR diagnosis with ICD-10-CM code fields, standardized assessment results table, specific intervention documentation, and clinician signature with supervisor countersignature line
• Editable Word document format allows practices to add their name and customize fields to reflect their specific clinical context and documentation requirements
• Fillable PDF format allows clinicians to complete notes digitally on any device — well suited for telehealth practice and for clinicians who prefer digital completion before uploading the finished note to their clinical record
• Purchasing the bundle provides all four templates at a significant savings compared to purchasing each individually

A Note on Choosing the Right Format: The right progress note format is the one that your setting requires, your payer accepts, and that captures the clinical information needed to demonstrate that what you did was skilled, necessary, and effective. Our bundle gives clinicians the flexibility to use the format that fits their current setting — and the resources to adapt when their setting changes. SOAP notes are most common in medical and multidisciplinary settings. DAP notes are widely used in outpatient counseling and private practice. BIRP notes are preferred in behavioral health agencies and managed care settings. GIRP notes are most common in community mental health and settings with close treatment plan oversight. All four are included.

References

• American Counseling Association. (2014). ACA Code of Ethics. American Counseling Association.
• American Psychological Association. (2019). Record keeping guidelines. American Psychologist, 74(4), 422–431.
• Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling & Development, 80(3), 286–292.
• Centers for Medicare and Medicaid Services. (2023). Medicare program integrity manual: Documentation requirements. Office for Civil Rights.
• Zuckerman, E. L. (2015). The Paper Office for Mental Health Professionals: Forms, Guidelines, and Resources to Make Your Practice Work Legally, Ethically, and Profitably (5th ed.). Guilford Press.