The Most Common Behavioral Health Clinical Notes and Their Differences

Behavioral health professionals employ a variety of standard note forms to document patient care. Progress notes are frequently written in formats such as SOAP, DAP, or BIRP, with defined portions. SIRP, a newer variation, is quite similar to BIRP. Other types of notes include intake/assessment notes, safety or risk assessments, crisis intervention notes, treatment plans, and discharge summaries.

Each note type has a specific purpose, structure, and length. Clear organization and substance are essential: SOAP notes are comprehensive and commonly used, whereas DAP notes condense information. BIRP notes emphasize behavioral observations and interventions. Intake notes record background and mental status early in care, while safety/risk notes use checklists and plans.

Progress notes are recorded in the official medical chart and can be seen by other physicians, insurance, and, in most cases, the patient. In contrast, private psychotherapy process notes must be kept separate and are not shared. Legal rules now often require sharing standard progress notes with patients.

Below, we compare the formats by structure, length, authors, and use cases. We also offer short example notes and tips for writing clearly. Throughout, we employ straightforward language to make the topic accessible to both ordinary readers and professionals.

What are Clinical Notes in Behavioral Health?

Clinical notes in behavioral health records the specific information found during encounters with clients, like mental health assessments, treatment plans, and progress.

The clinical observations, diagnoses, client-reported symptoms, therapy goals, and results of interventions are all recorded in the clinical notes. 

In behavioral health, those are found to be very important for recording conditions like:

• Depression 
• Anxiety 
• PTSD
• Substance use disorders.

They give providers a holistic overview of the client’s mental health journey, wherein they can estimate the effectiveness of treatment and adjust their strategies if necessary. 

Accurate and well-documented clinical notes also provide care continuity, inter-provider communication, and legal/insurance requirements; therefore, they essentially encourage both clinical and administrative excellence in patient care.

Related: How EHR Automation Tools Can Improve Clinical Notes for Behavioral Health

Commonly Used Behavioral Health Clinical Notes and Differences Between Them

1. Progress Note Formats (SOAP, DAP, BIRP, SIRP)

After each session or interaction, clinicians write progress notes to document what transpired and determine the next steps. There are numerous common structured formats:

SOAP notes (Subjective, Objective, Assessment, Plan)

The classic medical style.

• S (subjective): The client’s own reporting (feelings, symptoms, complaints).
• O (objective): Observable data (appearance, behavior, test findings, clinical observations).
• A (Assessment): The clinician’s interpretation (diagnosis updates, progress).
• P (Plan): The following stages (interventions, assignments, referrals).
• Example: “S: Client reports trouble sleeping and feeling more anxious this week.” O: Patient appeared tired, with fidgeting hands; anxiety scale score=8/10. A: Increased anxiety likely due to upcoming exam; no new triggers identified. P: Continue cognitive-behavioral therapy (CBT); practice relaxation exercises nightly; follow up in one week.”

SOAP notes are thorough and familiar to all healthcare providers. They are typically a few paragraphs long and are used in almost any scenario to justify treatment and bill insurance.

DAP notes (Data, Assessment, Plan)

A streamlined version of SOAP.

• Data: Combines subjective and objective information (client’s reports and clinician observations). For instance, client anxiety level, statements, and any measured data.
• Assessment: Clinician’s analysis of the data (progress toward goals, patterns, or obstacles).
• Plan: Same as in SOAP (next interventions and goals).

DAP notes are brief and goal-oriented, concentrating on what the client is doing and how therapy is going. DAP notes are frequently used by mental health counselors and social workers to write quickly while covering important content.

BIRP notes (Behavior, Intervention, Response, Plan)

Emphasize observable behavior.

• Behavior: Description of the client’s behavior or symptoms during the session.
• Intervention: What the clinician did.
• Response: How the client reacted.
• Plan: Next steps.
  BIRP is popular in community mental health and substance use settings because it clearly links interventions to client response. Notes can be bullet-format and are very focused on specific behaviors. Insurers often prefer the BIRP format as it highlights progress for each targeted behavior.

SIRP notes (Situation, Intervention, Response, Plan)

Similar to BIRP.

• Situation: The context or issue presented (like Behavior in BIRP). It captures the situation the client is in.
• Intervention: Clinician’s actions.
• Response: Client’s reaction.
• Plan: Future steps.
  SIRP is used by therapists and counselors as another way to structure progress notes. The “Situation” section may include the client’s own description of what’s going on. Overall, any progress note format can meet documentation requirements if done well.

Who writes/reads these notes? Usually, the treating clinician writes the note after the encounter. The intended audience is other healthcare providers and the patient. Progress notes document that medical necessity was met and help each new provider understand the client’s story.

After each therapy or medical visit. In group therapy, progress notes may include member participation. If your business has a specific format, use it; otherwise, select the one that allows you to be succinct and complete.

2. Intake and Assessment Notes

At the start of care, an intake or assessment note establishes the baseline. This note is frequently much longer and prepared by the clinician conducting the initial evaluation. It normally contains client identity information, reasons for seeking help, familial, social, and medical history, substance use, a mental state evaluation, risk factors, formal diagnoses, and early treatment recommendations.

For example, APA guidelines state that crucial components include noting the principal complaint, history of existing illness, current treatments, mental status evaluation, diagnosis, and treatment plan.

Provide a detailed summary of the client’s background and current status. This note guides all subsequent care. For example, you may write: “The client, a 25-year-old with a 5-year history of depression, is currently on sertraline 100mg. Reports a poor mood following the loss of his employment. There is no suicidal purpose, but the individual experiences passive ideas. Childhood anxiety and a family history of depression. Mental state: anxious mood, coherent thought. I’ve been diagnosed with Major Depression. Treatment plan: weekly individual CBT, medication maintenance, and weekly mood monitoring.

Entire care team. It often needs to stand alone so any clinician can pick up the file and know the client’s story. It may also include consent forms and administrative data.

Admission to a program or the start of outpatient care, and occasionally during major care changes.

Patient information, presenting problem, psychosocial history, risk assessment, mental state examination, tentative diagnosis, and follow-up strategy. Because these comments are incorporated into the medical chart, they must be truthful and useful.

3. Safety/Risk Assessment Notes

When there is fear that a client may endanger herself or others, a safety or risk assessment note is written. These notes are more specific and frequently employ structured techniques or checklists.

• Evaluate the current suicide risk, violence hazard, or other safety problems.
• Any clinician who determines a risk. If screening results are positive, a licensed clinician, in some situations, is required to do a formal suicide risk assessment.
• Often begins with the screening method, followed by information such as suicide ideation, precise plan or intent, previous attempts, protective variables, and risk level conclusion. It could end with a Safety Plan. Clinicians, for example, could use SAMHSA’s Safety Plan worksheet, which is a quick form for listing coping skills and contact information.
• Include questions like “Do you have any thoughts of harming yourself or others?” “Do you have a specific plan?” Take note of any recent stressors or substance usage. Document the client’s exact words for intent or plans.
• Other clinicians and emergency services. This note is often urgent care documentation.
• On intake, at crisis, or any time risk appears.

“Patient screened positive on PHQ-9 for passive suicidal thoughts. 

Client says, ‘I sometimes wonder if people would be better off without me,’ with no active plan. Protective factors: partner supportive, voluntary agreement to daily check-ins. Safety plan given. No hospitalization needed at present.”

4. Crisis Intervention Notes

A crisis note documents an acute event. It typically includes what precipitated the crisis, what was done, and the outcome.

• Record urgent interventions.
• Crisis team member, emergency clinician, or attending therapist.
• Usually narrative, in chronological order. It might cover: event description, immediate risk assessment, actions taken, patient’s response, and resolution.
• Ensures that all providers know exactly what crisis occurred and how it was handled. Often reviewed in case of legal or safety audits.
• Usually 1–2 pages, as needed to cover details.

Example: “At 3 pm, the client arrived very agitated after an argument. Reported hearing voices urging self-harm. Suicide screening: an active plan to overdose. The clinician promptly implemented a safety plan and contacted the crisis team. Following a one-hour assessment, the client agreed to a voluntary hospital admission.

Transported to the ER by staff. Behaviors: pacing, crying; vital signs normal. Medications: offered but declined. Outcome: Admitted for 48-hour observation. Family notified.”

Crisis notes may use some of the same fields as safety notes, but their urgency and detail focus distinguish them.

5. Treatment Plans

A treatment plan lays out therapy goals and methods. This note is usually written after assessment, and updated periodically.

• Define and document therapeutic goals, strategies, and responsibilities. Shows a “roadmap” for care, linking progress notes back to agreed targets.
• The primary clinician, often with client input. Sometimes insurers or programs require a standardized template.
• Commonly includes:
  • Problems/Goals: What issues to address.
  • Objectives: Specific, measurable steps.
  • Interventions: Modalities and actions.
  • Timeline/Review: Dates by which goals should be met or reviewed.
  • Responsible parties: Who will do each part?
• Varies by number of goals; could be ½–1 page or longer if many goals.
• Guides therapists and clients and tracks progress. Also used for insurance authorizations.
• The entire care team and the client. It should be understandable to non-professionals, showing what treatment steps are planned.

“Problem: Generalized anxiety interfering with sleep. Goals: 

1. Client will report improved sleep within 3 months. 
2. Client will reduce anxiety score from 20 to ≤14. 

Weekly CBT sessions, daily relaxation exercises, and consultation with a psychiatrist for prescription assessment. Responsible for the therapist to lead CBT, the client to do exercises; psychiatrist to assess medications. The review date is 12 weeks from now.

6. Discharge Summaries

A discharge summary is written when a client leaves a program or completes treatment. It wraps up the episode of care.

• Provide a concise summary of the entire treatment, so that future providers or records know what happened.
• Often, the last treating clinician or case manager. In an inpatient unit, the attending doctor usually completes it.
• Typically includes:
  • Reason for admission/referral and initial status.
  • Key interventions used and the client’s response.
  • Client’s condition at discharge and symptom levels.
  • Medications prescribed, follow-up appointments, referrals, and coping strategies.
  • Advice for continuing care or community resources.
• Usually between one and two pages. It should be comprehensive while remaining focused on the most important issues.
• Provides continuity of care. A new therapist or general practitioner reading the discharge narrative, for example, will discover why the patient was treated, what helped, and what to do next.

Example: “Reason for discharge: Client has completed 12 weeks of outpatient therapy after panic attacks. Treatment summary: Continued on sertraline, weekly CBT focusing on exposure and relaxation. 

By discharge, panic frequency reduced from 3/week to 1/week. No hospitalizations occurred. Current meds: sertraline 100mg. Client understands breathing techniques and has a safety plan. Follow-up: Referred to support group; see outpatient therapist monthly for two months; emergency contact given. Discharge condition: stable mood, no acute risk.”

Related: How Generative AI In Clinical Notes Transforms Medical Documentation

Comparison of Note Types

Note Type	Structure / Key Sections	Typical length	Who writes / Audience	Use case / When used
SOAP Progress Note	Subjective / Objective / Assessment / Plan	Short note	Treating clinician. Read by the care team and insurers.	Routine session documentation, medical visits, cover client report, clinician observations, assessment, and plan.
DAP Progress Note	Data / Assessment / Plan	Concise note (a few bullets/paragraphs)	Therapist or counselor. Read by care team.	Similar to SOAP, but “Data” mixes subjective and objective; good for goal-focused therapy.
BIRP Progress Note	Behavior / Intervention / Response / Plan	Bulleted list	Counselor, social worker, therapist. Read by team/insurer.	Emphasizes observable behavior and intervention effectiveness. Often used in community or substance-use settings.
SIRP Progress Note	Situation / Intervention / Response / Plan	Similar to BIRP (brief)	Therapist, social worker.	A variant focusing on situational context. Used like BIRP; each section aligns with practical session notes.
Intake / Assessment Note	Demographics; Chief complaint; History; Mental status; Risk; Diagnosis; Plan	Several pages (long)	Intake clinician. Read by the full team.	Initial comprehensive record at start of care. Captures complete background and baseline assessment.
Safety / Risk Assessment	Risk factors; Suicidal ideation/plan; Protective factors; Safety Plan	Moderate	Any clinician during a risk alert. Includes patient and care team.	Conducted when suicide/homicide risk is identified. Documents risk level and safety planning.
Crisis Intervention Note	Chronological event description; Risk check; Interventions; Outcome	Moderate	Crisis team or emergency provider. For the medical/legal record and team.	Records acute crises (suicide attempt, violent outburst, etc.), actions taken, and results.
Treatment Plan	Problems/Goals; Objectives, Interventions, Timeline, Review dates	Varies (½–1 page per goal)	Treating clinician & team. Read by the client and insurers.	Outline of therapy goals and methods at the start. Updated regularly to guide treatment progress.
Discharge Summary	Reason for discharge, Course of care, Current status, Recommendations	1–2 pages	Discharging clinician. Sent to the patient and future providers.	Summarizes the entire episode at the end of care. Used for continuity and records.

Example Note Templates

Example 1: SOAP Progress Note

• Subjective: “Client reports feeling more anxious about work; difficulty sleeping three nights this week.”
• Objective: “Appeared restless and spoke rapidly. Blood pressure 130/85. Functioning well at the job, but increased irritability noted.”
• Assessment: “Generalized Anxiety Disorder symptoms slightly worsened. No new stressors identified. Coping skills used inconsistently.”
• Plan: “Continued weekly CBT with focus on sleep hygiene. Taught deep breathing exercises. Agreed to keep sleep diary. Follow up in 1 week.”

Example 2: BIRP Progress Note

• Behavior: “Client came to session tearful, stating, ‘I snapped at my partner today and felt guilty.’ She reports irritability this week and avoiding social events.”
• Intervention: “Conducted cognitive restructuring exercise focusing on anger triggers. Modeled assertive communication techniques. Explored the connection between thoughts and reactions.”
• Response: “Initially resistant but gradually engaged in the role-play. By session end, the client said, ‘I see how changing my thoughts could help.’ No crying by the end of the session; appeared relieved.”
• Plan: “Client will practice identifying angry thoughts in a journal this week. Agreed to use the ‘time-out’ technique at home when feeling irritability rising. Continue cognitive therapy next session.”

These examples use plain language, quoting the client’s words and focusing on facts and plans. Notice how each section is concise and labeled for clarity.

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