Mental Health Note Template

Key Takeaways

Multiple progress note formats exist-SOAP, DAP, BIRP-each suited to different clinical settings and training backgrounds.

Mental health note templates must balance clinical detail with HIPAA compliance and efficient documentation workflows.

Psychotherapy notes receive heightened legal protections under 42 CFR Part 2, distinct from standard progress notes.

Standardised templates reduce documentation errors and improve continuity of care across therapy teams.

What Is a Mental Health Note Template?

A mental health note template is a structured clinical documentation tool used by therapists, counsellors, psychiatrists, and psychologists to record patient encounters, treatment progress, and therapeutic interventions. These templates provide a standardised framework for capturing essential clinical information whilst ensuring compliance with regulatory requirements and professional standards.

Mental health notes serve multiple purposes. They create a continuous clinical record that supports continuity of care when multiple providers work with the same patient. They document treatment modalities, patient response to interventions, and progress toward therapeutic goals. They also generate the audit trail required by healthcare regulatory bodies including the American Psychological Association (APA), the National Association of Social Workers (NASW), and the American Counseling Association (ACA).

Under HIPAA (Health Insurance Portability and Accountability Act) and 42 CFR Part 2, mental health documentation carries specific legal requirements. Psychotherapy notes-those recording the content of therapy sessions-receive heightened privacy protections compared to progress notes, which document clinical observations and treatment decisions. Understanding this distinction affects what information belongs in each section of your mental health note template.

Download Your Free Mental Health Note Template

This free mental health note template provides a ready-to-use framework that works with any EHR system or paper-based record system. Whether you’re documenting a first intake session, ongoing therapy progress, or psychiatric evaluation, this template supports both clinician efficiency and regulatory compliance without requiring proprietary software.

Types of Mental Health Note Formats and Structures

Different clinical training traditions favour different documentation structures. Understanding each format helps you choose the structure that aligns with your clinical background, your agency’s requirements, and your patient population’s needs. The five most widely used formats are SOAP, DAP, BIRP, GIRP, and PIE-each with distinct organisational logic.

SOAP Mental Health Note Format (Subjective, Objective, Assessment, Plan)

SOAP is the most widely taught progress note format in medical and nursing education. The structure separates patient-reported experience (Subjective) from observable clinical data (Objective), clinical interpretation (Assessment), and the documented treatment plan (Plan). This format works well for clinicians documenting across inpatient and outpatient settings. Each SOAP section serves a distinct clinical purpose: Subjective captures the patient’s own description of symptoms and experiences; Objective records measurable findings, vital signs, observations, and assessment results; Assessment documents your clinical interpretation of the data and any diagnostic considerations; Plan outlines the specific interventions, referrals, and follow-up schedule.

DAP Mental Health Note Format (Data, Assessment, Plan)

DAP notes condense the SOAP structure by combining subjective and objective information into a single “Data” section. This format is common in social work, community mental health agencies, and outpatient therapy settings. The condensed structure reduces documentation time whilst preserving clinical content. Data encompasses both client statements and your clinical observations; Assessment documents your clinical understanding and any diagnostic impressions; Plan specifies treatment direction and interventions. Many therapists favour DAP for its efficiency in busy clinic environments.

BIRP Mental Health Note Format (Behavior, Intervention, Response, Plan)

BIRP organises notes around observable behaviour and therapeutic response. This format emphasises what the patient does and how they respond to specific interventions, making it particularly suited to mental health practice management in behavioural health settings. Behavior documents specific observable actions, emotional presentations, and reported symptoms; Intervention describes the exact therapeutic technique, modality, or clinical action you provided; Response captures how the patient responded-verbally, emotionally, and behaviourally; Plan outlines the next therapeutic steps and any between-session assignments.

GIRP and PIRP Formats

GIRP (Goals, Intervention, Response, Plan) centres documentation around stated therapeutic goals, useful for goal-focused therapy and coaching. PIRP (Problem, Intervention, Response, Plan) organises around identified problems. Both formats work well when your therapy explicitly tracks progress against defined objectives. Choose whichever format aligns with how your treatment planning already structures clinical work.

Regulatory bodies do not mandate a specific format. Any structure meeting content requirements-demographic data, presenting concerns, treatment history, clinical observations, assessment results, diagnostic impressions, treatment plan, and follow-up instructions-satisfies HIPAA and professional licensing board standards. Learn more about best practices for mental health documentation across different clinical settings.

Your choice should prioritise clarity for your team and continuity for your patients.

Best Practices for Writing Mental Health Progress Notes

Effective mental health note templates balance completeness with efficiency. These practices apply across all formats. Write objectively without editorialising-describe what you observe and what the patient reports, not your subjective impressions of their character or worthiness. A note reading “patient is difficult” fails clinically and legally. A note reading “patient expressed frustration with previous providers and requested a change in therapy approach” documents observable communication and clinical need.

Use specific language rather than vague labels. Replace “client seems anxious” with “client reported racing thoughts and a tightness in chest; speech rate increased; hands trembling during session.” Specificity aids treatment continuity and supports your clinical reasoning if records are ever reviewed. Document the mental status examination elements relevant to the session-appearance, mood, affect, speech patterns, thought organisation, memory, and insight. Not every element needs documentation every visit; record what is clinically relevant to the day’s presenting concerns and treatment focus.

Include the specific therapeutic intervention you provided. “Provided therapy” is insufficient. Document the modality (CBT, DBT, motivational interviewing, psychodynamic exploration) and the specific technique applied (cognitive restructuring, values clarification, grounding exercise). This precision supports insurance review, demonstrates the medical necessity of your care, and creates the clinical record needed for your licensing board. Review official mental health documentation requirements for Medicare billing compliance.

Document informed consent elements when introducing new treatments or modalities. Record any safety discussions, particularly for patients with suicidal ideation, self-harm risk, or substance use. Safety planning, crisis resources provided, and emergency contact confirmation belong in the note. If you referred the patient to emergency services, psychiatric hospitalisation, or specialist care, document the reason, what you communicated, and the patient’s response.

HIPAA Compliance and Legal Protections for Mental Health Notes

HIPAA requires that all patient health information, including mental health notes, be protected from unauthorised access. Your mental health note template must support this compliance through content design. Store notes in secure systems with access restricted to authorised clinical staff. Encrypt notes stored electronically. Use digital intake forms rather than paper whenever possible to minimise physical record exposure.

42 CFR Part 2 creates an additional layer of protection for substance use disorder (SUD) treatment records. If you document substance use treatment or recovery support in a mental health note, that record receives heightened confidentiality protections. Separate psychotherapy notes-those documenting the content of therapy sessions-from progress notes for an extra safeguard. Research on sharing mental health notes with patients shows how transparency affects the therapeutic relationship.

Psychotherapy notes may include sensitive clinical material, personal feelings expressed in session, or theoretical formulations; progress notes focus on observable behaviours, treatment decisions, and clinical observations. Keeping these separate limits exposure if records are subpoenaed.

Do not document assumptions about diagnosis, prognosis, or treatment outcome. Stick to what you observe, what the patient reports, and your clinical assessment based on recognised assessment instruments. Never include your personal reactions, judgements about the patient’s lifestyle, or speculations about motivation beyond what the clinical data supports. This protects your professional standing and your patient’s privacy simultaneously. International experts have documented the benefits and harms of open notes in mental health practice.

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Who Benefits from a Mental Health Note Template?

Mental health note templates serve diverse clinical settings and professional disciplines. Therapists and counsellors in private practice use templates to maintain consistent documentation standards across a growing caseload. Solo practitioners benefit from templates that enforce the documentation discipline that comes naturally in larger agencies but requires deliberate systems in solo practice.

Community mental health clinics serving uninsured and under-insured populations depend on progress note templates that support both clinical continuity and billing documentation-often using the same note to serve clinical and administrative purposes. Psychiatric nurses in hospital settings use templates adapted for inpatient acuity; psychiatrists in private practice adapt templates for brief medication management visits. Occupational therapists and other rehabilitation specialists use mental health note structures when documenting cognitive, functional, or psychosocial aspects of treatment. Psychology doctoral trainees and new therapists benefit from structured templates that guide clinical observation and treatment planning until the structure becomes automatic.

Agencies with multiple clinicians-from a three-person group practice to a large community mental health centre-benefit from standardised templates that create consistency in what each note captures, enabling warm handoffs when clinicians cover for each other and supporting supervision and clinical review. Multi-disciplinary teams benefit further: when all team members use the same template structure, psychiatric medication notes, therapy notes, and psychiatric nursing assessments fit together coherently in a shared patient record.

Benefits of Using a Structured Mental Health Note Template

Standardised templates reduce documentation time without sacrificing clinical completeness. A well-designed template acts as a checklist, prompting clinicians to document elements they might otherwise skip in a busy day-ensuring safety considerations, informed consent discussions, and treatment planning all get recorded. This consistency improves clinical outcomes. When each note contains the same key elements, clinicians covering cases or providing supervision can quickly locate critical information.

Templates improve compliance with regulatory requirements. Licensing boards review notes for specific content-documentation of informed consent, safety assessment, treatment planning, and progress measurement. Agencies audited by CMS (Centers for Medicare & Medicaid Services) or state Medicaid programs are evaluated partly on note quality. A template designed with these standards built in makes compliance automatic rather than something to chase retroactively.

Structured notes support billing and insurance claims. Insurance companies reviewing prior authorisation requests and medical necessity determinations rely on note documentation to justify the level of care and specific interventions provided. A template ensuring that clinical detail appears consistently strengthens claims and reduces denials. Documentation of treatment response, functional improvement, and progress toward goals-elements a template prompts you to include-demonstrates medical necessity more effectively than vague summaries.

Using AI-powered clinical documentation systems alongside templates further accelerates note generation. After a session, clinicians can dictate observations, therapeutic techniques, and the patient’s response; AI transforms this into structured note format within seconds. This hybrid approach preserves clinical detail whilst reclaiming time otherwise lost to typing.

Mental Health Progress Notes for Telepsychiatry and Remote Sessions

Telepsychiatry and remote therapy sessions require minor adaptations to standard mental health note templates. In telehealth settings, observable data shifts. You cannot physically assess vital signs or observe full body behaviour; instead, you document what the video platform reveals. Note the quality of the video and audio connection-were there interruptions? Did technical issues affect session continuity? Document the patient’s home environment if clinically relevant (visible cues to safety, distractions) but respect privacy; do not over-document environmental details. Some patients disclose their home situation for a reason; others prefer privacy. Your note should reflect the clinical relevance of what you observed.

Record whether the patient accessed the session in a private location and whether other household members were present. This matters for safety assessment and informed consent-if a patient is reporting intimate partner violence but a partner is visible on-screen, your assessment changes. Document any technological barriers: patients struggling with the platform, connection drops, or inability to use the video feature (phone-only sessions). These factors legitimately affect therapeutic engagement and pace.

Telepsychiatry notes need explicit documentation of how you conducted safety assessments given remote limitations. A patient report of suicidal ideation seen in-person allows direct mental status observation; the same report via video requires explicit questioning about access to means and verification of a safety plan. Your note should reflect this adapted assessment process. If you cannot safely assess a patient remotely, document what specifically prevents safe care (patient substance-intoxicated, unable to guarantee privacy, safety risk that requires in-person evaluation) and the clinical action taken.

Mental Health Progress Notes When Patients Have Comorbid Conditions

Patients with comorbid psychiatric and medical conditions require mental health note templates that document both domains clearly. Your progress note should record psychiatric symptoms and therapeutic progress whilst also tracking medical conditions relevant to mental health treatment. A patient on multiple antidepressants benefits from notes documenting mood, energy, sleep, and appetite-psychiatric outcomes-whilst also tracking blood pressure, weight, and metabolic screening-medical outcomes that psychotropic medications affect.

When documenting comorbidity, clarify the treatment hierarchy: which condition is primary today, and how are the conditions interacting? Untreated sleep apnoea can worsen depression and anxiety. Uncontrolled diabetes complicates antipsychotic medication tolerance. Your note should reflect these interactions and how treatment addresses both. Document any medical referrals you place: “Referred patient to primary care for sleep study given untreated sleep apnoea and worsening depression.” This creates continuity and demonstrates awareness of the whole patient.

In notes for patients with substance use disorders, document whether substance use is active, in remission, or historical; whether the patient is engaged in treatment (medication-assisted therapy, peer support, rehabilitation); and how substance-related risk affects current psychiatric symptoms and medication safety. A patient on benzodiazepines with active alcohol use requires explicit risk documentation and intervention planning. Templates should prompt this documentation automatically rather than relying on the clinician to remember to raise it.

Expert Picks

Want to standardise note templates across your mental health team? Mental Health EMR Solutions guide outlines how clinic software supports consistent documentation workflows and multi-clinician collaboration.

Need to document comorbid conditions comprehensively? Psychiatric Evaluation Template shows how to structure notes that capture both psychiatric and medical assessment elements in one coherent record.

Looking to automate note generation? AI Scribes in Mental Health explores how clinicians use dictation and AI assistance to speed documentation whilst maintaining clinical accuracy.

Conclusion

A mental health note template is more than a form-it is a clinical system that ensures nothing important is missed, supports regulatory compliance, and creates the continuous care record that protects both patient and clinician. Whether you adopt SOAP, DAP, BIRP, or another format, the template should reflect your clinical setting, support your documentation discipline, and make compliance automatic rather than aspirational.

The template we’ve provided works across all practice settings and integrates with any EHR system or paper record. Download it, test it with your team, adapt it to your specific needs, and build it into your routine. Good documentation today becomes the clinical evidence you need if questions arise later-and more importantly, it creates the record that supports each patient’s continuity of care across therapy relationships and clinical transitions.

Frequently Asked Questions