If someone else will read the note
SOAP. Separating what was reported from what was observed is what lets a third party reread it without decoding your shorthand.
Clinical note templates
Seven templates ready to copy: the four session-note formats the profession uses — SOAP, DAP, BIRP and GIRP — plus the intake session, the treatment plan and the discharge note. With what goes in each field and when each one fits. No sign-up.
Which one to use
All four record the same session. What changes is what they force you to write, and therefore what is lost if you choose wrong.
If only you will read it
DAP. Same information, one seam fewer, half the time.
If the intervention has to be justified
BIRP. The only one that makes you write what you did and how the patient responded to that specific thing.
If you work to measurable goals
GIRP. Every note names the plan goal it works on, and progress reads vertically across the whole process.
The templates
Plain text, so they survive being pasted into whatever you already use. Open them and copy them.
SOAP
The health-care standard. It separates what the patient reports from what you observed, which is exactly what saves a note when another professional — or a court — reads it.
- S — Subjective — what the patient reports, quoted where the wording matters
- O — Objective — what is observable: affect, psychomotor activity, speech, scale scores
- A — Assessment — your clinical reading: hypotheses, progress against goals, risk
- P — Plan — what happens before the next session and what it will cover
When to use it: Use it when the note has to work outside your own head: referrals, reports, team working, or any formal health-care setting.
See the full template
SESSION NOTE Patient: ____________________ Record no.: __________ Date: ____/____/______ Session no.: ______ Format: in person / online Duration: ______ min S — SUBJECTIVE Reason for this session and state since the last one: What the patient reports (quote directly where the wording matters): Changes in sleep, appetite, energy, substance use: Adherence to agreed between-session tasks: O — OBJECTIVE Appearance and psychomotor activity: Observed affect and mood: Speech and thought process: Instruments administered and scores (scale, date, result): A — ASSESSMENT Clinical hypothesis for this session: Progress against the treatment plan goals: Risk and protective factors (ideation, self-harm, substance use, support network): Therapeutic alliance and observed obstacles: P — PLAN Intervention planned for the next session: Tasks agreed with the patient: Referrals, coordination or pending assessments: Next appointment:
DAP
SOAP without the seam between subjective and objective. Faster to write, and enough when you are the only person who will read the note.
- D — Data — everything relevant from the session, reported and observed, undivided
- A — Assessment — what that means clinically
- P — Plan — the next step, concrete and dated
When to use it: Use it in private practice, in long stable processes, or when session volume turns SOAP into a tax.
See the full template
SESSION NOTE Patient: ____________________ Record no.: __________ Date: ____/____/______ Session no.: ______ Format: in person / online Duration: ______ min D — DATA Session content (patient report and clinical observation): Relevant events since the last session: Adherence to tasks and to the frame: Instruments administered and scores: A — ASSESSMENT Clinical reading of the above: Progress against the agreed goals: Risk assessed in this session: Adjustments to the case formulation: P — PLAN Focus of the next session: Agreed tasks: Coordination, referral or pending assessments: Next appointment:
BIRP
The only one of the four that makes you write down what you did. It records the intervention and how the patient responded to it, not just how they arrived.
- B — Behaviour — what was presented and observed at the start of the session
- I — Intervention — what you did: technique, frame, materials, duration
- R — Response — how the patient responded to that specific intervention
- P — Plan — what stays, what is adjusted, and what comes next
When to use it: Use it when the intervention has to be justified: third-party payers, protocol-driven programmes, supervision, or any manualised technique.
See the full template
SESSION NOTE Patient: ____________________ Record no.: __________ Date: ____/____/______ Session no.: ______ Format: in person / online Duration: ______ min B — BEHAVIOUR Presentation at the start of the session: Target symptoms and behaviours observed: Patient's account of the week: I — INTERVENTION Techniques used (name, protocol, approximate duration): Content worked through and materials used: Adjustments to the frame during the session: R — RESPONSE Patient's response to the intervention: Level of engagement and resistance observed: Changes within the session itself: P — PLAN Continue or modify the technique: Agreed tasks: Goals for the next session: Next appointment:
GIRP
BIRP anchored to the treatment plan: every note opens by naming the goal it works on, so progress reads at a glance across the whole process.
- G — Goal — the treatment-plan goal being worked on today
- I — Intervention — what you did to move that goal forward
- R — Response — the progress observed, with a measure where one exists
- P — Plan — the next step towards that same goal
When to use it: Use it in goal-directed treatment, time-limited work, or wherever measurable progress has to be demonstrated.
See the full template
SESSION NOTE Patient: ____________________ Record no.: __________ Date: ____/____/______ Session no.: ______ Format: in person / online Duration: ______ min G — GOAL Treatment plan goal worked on in this session: Agreed progress indicator for that goal: Starting point at the beginning of the session: I — INTERVENTION Techniques and interventions aimed at that goal: Materials and tasks used: R — RESPONSE Progress observed against the indicator (measure or description): Obstacles that came up: Relevant statements by the patient: P — PLAN Next step towards the goal: Agreed tasks: Treatment plan review: yes / no — reason: Next appointment:
Intake session
The session everything else rests on. It gathers the presenting problem, the history, the risk and the agreements of the frame into one document.
- Details and reason — who is here, why now, and what they expect
- History — relevant biography, previous episodes and treatment
- Risk — the part that is not left for later
- The frame — fees, cancellation, confidentiality and consent
When to use it: At the first session, always. And again if the work reopens after discharge or a long break.
See the full template
INTAKE SESSION — FIRST INTERVIEW Patient: ____________________ Record no.: __________ Date: ____/____/______ Referred by: ______________ 1. DETAILS AND PRESENTING PROBLEM Age, living situation, occupation: Presenting problem in the patient's own words: Why now (what changed that led to this appointment): Expectations of therapy: 2. HISTORY OF THE PROBLEM Onset, course and development: Previous attempts at a solution and their outcome: Precipitating and maintaining factors: 3. PERSONAL AND FAMILY HISTORY Relevant biography: Psychological and psychiatric history (personal and family): Previous treatment and current medication: Relevant physical health: 4. MENTAL STATE EXAMINATION Appearance, affect, speech, orientation: Instruments administered and scores: 5. RISK ASSESSMENT Suicidal ideation: none / passive / active — plan: yes / no Self-harm, substance use, risk behaviours: Protective factors and support network: Agreed response in the event of a crisis: 6. IMPRESSION AND FORMULATION Explanatory hypothesis for the case: Diagnostic impression (where applicable): 7. AGREED GOALS AND FRAME Initial treatment goals: Planned frequency and duration: Fees and cancellation policy explained: yes / no Informed consent given and signed: yes / no Specific consent for recording / AI assistance: yes / no / not applicable 8. INITIAL PLAN Focus of the next sessions: Agreed tasks or self-monitoring: Referrals or coordination needed: Next appointment:
Treatment plan
The document that turns “coming to therapy” into goals with an indicator and a review date. It is also what makes progress legible when the work runs long.
- Formulation — the hypothesis that organises the work
- Goals — three to five, written as observable behaviour
- Indicators — how you will both know something has moved
- Review — when this document gets looked at again
When to use it: After the first two or three assessment sessions, and at every agreed review of the treatment.
See the full template
TREATMENT PLAN Patient: ____________________ Record no.: __________ Date written: ____/____/______ Review due: ____/____/______ 1. CASE FORMULATION Explanatory hypothesis: Predisposing, precipitating and maintaining factors: Patient's strengths and resources: 2. TREATMENT GOALS Goal 1: Progress indicator: Planned interventions: Estimated timeframe: Goal 2: Progress indicator: Planned interventions: Estimated timeframe: Goal 3: Progress indicator: Planned interventions: Estimated timeframe: 3. APPROACH AND TECHNIQUES Theoretical framework: Main techniques planned: Frequency and estimated number of sessions: 4. RISK AND CRISIS PLAN Identified risks: Agreed warning signs: Response and contacts in the event of a crisis: 5. COORDINATION Other professionals involved: What information is shared and under which consent: 6. REVIEW Review date: Criteria for changing the plan: Criteria for discharge:
Closing or discharge note
Closes the work in writing: what was worked on, what changed, what is unfinished and what to do if the person comes back. It is the note your future self thanks you for.
- Reason for closing — agreed discharge, drop-out, referral or transfer
- Summary — the whole process in one readable paragraph
- Outcome — goals met and unmet, with the indicator
- Continuity — what to do if the person returns
When to use it: At an agreed discharge, when treatment is abandoned, and at any referral that ends your involvement.
See the full template
CLOSING / DISCHARGE NOTE Patient: ____________________ Record no.: __________ Start date: ____/____/______ Closing date: ____/____/______ Total number of sessions: ______ 1. REASON FOR CLOSING Agreed discharge / drop-out / referral / transfer / other: Description: 2. SUMMARY OF THE WORK Original presenting problem: Formulation and main interventions: Development over the course of the work: 3. OUTCOME Goals met (with indicator): Goals partially met or unmet: First and final scores on the instruments administered: 4. SITUATION AT CLOSING Current clinical state: Risk at the point of discharge: Resources and strategies acquired: 5. CONTINUITY Recommendations given to the patient: Referral made (professional, service, date): Warning signs that should prompt them to seek help again: Whether and how the case can be reopened: 6. DOCUMENTATION Discharge report given: yes / no Copy of the clinical record requested by the patient: yes / no Record retention period: ______ years
Adapt them before you use them. A template is scaffolding, not a mandatory form. Remove the fields your approach does not use and add the ones it does: a note with empty slots is worse than a short note. And remember the clinical record is a document with legal obligations on both content and retention in your jurisdiction.
These templates, already inside the clinical record
Copy and paste works until session thirty. In Alchely note templates are part of the dashboard: you pick the format when you open the session, the note is filed against the patient and the date, and you can build your own. We are in open beta: come in as an early adopter and the first year is free.
No card. No countdown.