BIRP NOTE

Client: [Name or ID]
Date: [Date of service]
Time: [Start and end time, total minutes]
Service: [Individual therapy, skills session, group, family session, or case management contact]
Setting: [Office, group home, residential unit, school, home, or video, with the client's location if remote]
Present: [Client only, or each person by role]
Plan goal served: [Goal and objective by number, worded as on the current treatment plan]
Staff: [Name, credentials, role]

BEHAVIOR
Client's report: [What the client said about the target behavior or symptoms since the last session, with a short quote]
Counts and logs: [Frequency from the client's diary, a staff log, or incident reports, beside the previous count]
Others' reports: [What staff, family, or other providers described, with who said it and over what period]
Seen today: [Appearance, eye contact, speech, activity, and how the client engaged]
Mood and affect: [Mood in the client's words; affect as you saw it]
Thinking and perception: [Thought process, and any voices, unusual beliefs, or intrusive thoughts the client describes]
Scores: [Any measure given today, beside the last result]
Risk screen: [Suicidal thoughts, self-harm, harm to others, and substance use: the questions and the answers]

INTERVENTION
Approach: [The model or service: CBT, skills training, DBT skills, motivational interviewing, psychoeducation, or case management]
Steps taken: [Each technique by name and what it involved, in the order used]
Target of each step: [The behavior or objective each step was aimed at]
Help given: [Prompts, modeling, script cards, handouts, or other changes to fit the client]
Contacts: [Calls or messages to staff, family, or providers, and the consent for each]

RESPONSE
Participation: [How the client took part, and anything offered and declined]
Skill shown: [What the client did in session, and how many prompts or tries it took]
Before and after: [Ratings, counts, or scores at the start and the end, or beside the baseline]
Client's view: [What the client said about the session, in their words]
Progress on the objective: [Met, progressing, unchanged, or worse, with the evidence]
Clinical impression: [Your judgment of what today's behavior and response mean, and your risk judgment]

PLAN
Client tasks: [Practice or steps before the next session, how often, and how they will be tracked]
Staff and provider tasks: [Who will do what, and by when]
Supports: [Prompts, staff support, safety plan, or the crisis line 988, call or text]
Next session: [Date, time, setting, and focus]
Plan changes: [New or revised goals, frequency, or level of care, or none]

Signature: [Name, credentials, date and time signed]