Therapy Note Format Examples (SOAP vs DAP vs BIRP)

Therapy Note Examples

Client: Sarah T., 34-year-old marketing professional

Date: October 27, 2025

Therapist: Dr. Michael Chen, LCSW

SOAP Format Example

S (Subjective): Sarah reported increased workplace stress following a recent promotion. She described difficulty "turning off" her thoughts at night, resulting in 4-5 hours of sleep per night over the past two weeks. Client stated she feels "constantly on edge" and has been avoiding social engagements. She denied suicidal ideation but expressed concern that she's "heading toward burnout."

O (Objective): Client presented with tired appearance and dark circles under eyes. Maintained good eye contact throughout session. Speech was coherent but faster-paced than previous sessions. Posture was tense with visible shoulder tension. Client demonstrated good insight into her stress patterns and showed willingness to engage in intervention discussion.

A (Assessment): Sarah continues to meet criteria for Generalized Anxiety Disorder (mild to moderate severity). Current work stressors have exacerbated symptoms, particularly sleep disturbance and physical tension. Client shows good prognostic indicators including strong insight, motivation for change, and previous positive response to CBT techniques. No indication of safety concerns at this time.

P (Plan): Continue weekly CBT-focused sessions. Introduced sleep hygiene protocol and progressive muscle relaxation technique. Assigned daily practice of PMR before bed and tracking of sleep patterns/anxiety levels using provided log. Client agreed to reduce caffeine intake after 2pm. Will reassess sleep improvements and anxiety levels at next session. If symptoms worsen or sleep does not improve within 2 weeks, will discuss potential psychiatric consultation for medication evaluation.

DAP Format Example

D (Data): Sarah discussed escalating work demands since her promotion three weeks ago, describing persistent worry about performance and meeting expectations. Sleep has decreased to 4-5 hours nightly with difficulty both falling asleep and staying asleep. She reports physical tension, particularly in shoulders and jaw, and has declined social invitations from friends twice this week. Client appeared fatigued with tense posture but engaged actively in session and demonstrated good insight regarding the connection between her thoughts and physical symptoms.

A (Assessment): Sarah's anxiety symptoms have intensified in response to situational stressors (work promotion). While she continues to meet GAD criteria, her symptoms remain in the mild-to-moderate range. She shows positive engagement in treatment and understanding of cognitive-behavioral concepts introduced in previous sessions. Sleep disturbance is the most pressing symptom affecting her functioning. Client retains adequate coping skills and social support, with no current safety concerns.

P (Plan): Will continue with weekly therapy sessions focusing on CBT interventions for anxiety management. Taught progressive muscle relaxation and reviewed sleep hygiene principles. Sarah will practice PMR nightly, implement sleep hygiene recommendations (including caffeine reduction after 2pm), and complete anxiety/sleep log throughout the week. Next session will review log data, assess intervention effectiveness, and potentially introduce cognitive restructuring techniques for work-related worry thoughts. Will consider psychiatric referral if sleep does not improve within two weeks.

BIRP Format Example

B (Behavior): Sarah presented with visible signs of fatigue including dark circles and heavy eyelids. She reported feeling "wired but exhausted" and described a pattern of ruminating thoughts about work performance at night. Client engaged actively in session discussion, spoke at a faster pace than baseline, and demonstrated physical tension through posture and frequent hand-wringing. She expressed frustration with her inability to "shut down" after work hours.

I (Intervention): Provided psycho-education on the relationship between anxiety, physical tension, and sleep disturbance. Introduced progressive muscle relaxation (PMR) technique and guided Sarah through practice during session. Reviewed sleep hygiene principles including consistent sleep/wake times, bedroom environment optimization, and reducing screen time before bed. Explored cognitive patterns maintaining nighttime worry and introduced thought-stopping technique.

R (Response): Sarah reported noticeable muscle relaxation during guided PMR practice and expressed surprise at how much tension she was holding. She demonstrated good understanding of sleep hygiene concepts and identified several areas for modification (late-night email checking, irregular sleep schedule on weekends). Client expressed cautious optimism about practicing techniques at home but voiced concern about remembering steps for PMR without guidance. Agreed to use provided audio guide.

P (Plan): Sarah will practice PMR nightly using provided audio guide and implement sleep hygiene modifications discussed. She will track sleep duration, anxiety levels (0-10 scale), and PMR practice compliance in provided log. Next session will review log, assess technique effectiveness, and introduce cognitive restructuring for work-related worry thoughts. Will monitor sleep improvement; if significant disturbance persists after two weeks of consistent intervention, will discuss benefits of psychiatric consultation for adjunctive medication support.