A DAP note records a counseling or therapy session in three parts: Data, Assessment, and Plan. Copy the free template, see a CBT anxiety and a substance use counseling example, and learn what belongs in Data and what belongs in Assessment.
Blank DAP note template
FreeDAP NOTE Client: [Name or ID] Date of session: [Date] Session: [Number, start and end time, total minutes] Format: [Individual, couple, or family; in person, video, or phone; client's location if remote] Others present: [Name and relationship, or none] Focus of care: [Diagnosis or problem from the treatment plan] Clinician: [Name, credentials] DATA Client report: [What the client said about the time since the last session, with a short quote where it helps] Observations: [What you saw: appearance, behavior, eye contact, speech, mood in the client's words, affect] Measures and results: [Scale scores today beside the last ones, or test results, with dates] Homework: [What was agreed last time, and what the client actually did] In session: [Topics covered and each technique you used, named so a colleague could repeat it] Risk questions: [What you asked about suicide, self-harm, and harm to others, and the client's answers] ASSESSMENT Clinical impression: [What today's data means, and how it fits the diagnosis or focus of care] Response to the work: [How the client took to today's techniques, and what that tells you] Progress toward goals: [Each treatment plan goal by number: improving, no change, or setback, citing the data] Risk judgment: [Your view of current risk, low, moderate, or high, and the reasons] Helping and hindering: [Strengths, supports, and barriers that affect what comes next] PLAN Between sessions: [Homework or practice the client agreed to, with when and how often] Next focus: [What the next session will work on, and why] Changes to care: [Session frequency, level of care, or treatment plan updates, or none] Coordination: [Referrals or contact with other providers, with the client's consent] Safety steps: [Safety plan reviewed or updated, crisis contacts given, or none needed] Next session: [Date, time, and format] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Private practice, individual session, in person
Session 7 of individual CBT, 50 minutes, in person. No one else present. Focus of care: generalized anxiety disorder, as set out in the treatment plan.
54-year-old woman. Says she worried “less often, but just as hard” this week: about 2 hours a day, down from 4 at intake. Main worry was her daughter’s 5-hour drive home from university on Friday. Used her daily worry period on 5 of 7 days. Cut reassurance texts to her daughter from about 10 a day to 3, but checked the highway traffic map “every half hour” on Friday afternoon. Falling asleep within 30 minutes on most nights. Observed: neatly dressed, sat forward, picked at her sleeve while describing Friday. Speech normal in rate. Mood “a bit lighter”; affect anxious, brighter when talking about her garden. GAD-7 11, down from 13 two weeks ago and 16 at intake. PHQ-9 6. In session: reviewed the worry log; identified the belief “if I don’t check, I’m a careless mother”; Socratic questioning and a cost-benefit review of checking. Belief rated 70% at the start and 45% at the end. Planned a behavioral experiment together. Risk questions: denies suicidal thoughts, self-harm, and thoughts of harming others.
Generalized anxiety disorder, improving. The GAD-7 has moved from the severe to the moderate range, and time spent worrying has halved. Reassurance seeking is falling, but checking has moved from texting to the traffic map: the same safety behavior in a new form, which keeps the belief that checking protects her daughter. The drop in her belief rating suggests she is ready to test it. Goal 1, less time worrying: improving. Goal 2, less reassurance seeking: partly met. Mild low mood seems to follow the worry rather than stand alone. No current risk of harm to herself or others.
Behavioral experiment for her daughter’s drive back on Sunday: no texts and no traffic map until her daughter calls on arrival. Rate anxiety at the start, after 1 hour, and after the call, and write down what happened. Keep the daily worry period. Next session: review the experiment, then apply the same work to uncertainty about her own health. No change to care: weekly CBT, GAD-7 every 2 weeks. No coordination needed. Next session in 1 week, in person.
Outpatient addiction program, individual counseling, in person
Individual counseling, 45 minutes, in person, week 16 of outpatient treatment. Focus of care: opioid use disorder, severe, on buprenorphine-naloxone 16 mg daily from the program’s prescriber.
32-year-old woman. Disclosed at the start of the session, before any test, that she used fentanyl once on Sunday night, 2 days ago, after her ex-partner turned up at her apartment. He left after 20 minutes when she asked; she says he has never been violent. Smoked it alone in her bathroom; no loss of consciousness. Took buprenorphine every day, Sunday included. First use in 11 weeks. Cravings 7 out of 10 since Sunday, from 2 or 3 on most days before. Has not told her sister, her main support. Her naloxone kit is in her car, not at home. Observed: on time, alert, speech clear, no signs of intoxication or withdrawal. Tearful and looked down while describing Sunday; steadier once planning began. Urine drug test collected today: positive for buprenorphine and fentanyl, negative for other opioids, stimulants, and benzodiazepines. In session: chain analysis of Sunday, from the knock at the door to use; motivational interviewing about her next steps; explained that buprenorphine lowers but doesn’t remove overdose risk, and that using alone raises it. Risk questions: says she used “to stop feeling it,” not to die. Denies suicidal thoughts on Sunday or now, self-harm, and thoughts of harming others. No past suicide attempts. Named her job, her sister, and “not throwing away 11 weeks” as reasons to keep going.
A single lapse, not a return to regular use: one episode after a clear trigger, with daily buprenorphine kept up. Disclosing it before the test result shows trust in treatment, a strength to build on. The trigger, contact from her ex-partner, is missing from her relapse prevention plan. High cravings and keeping the lapse from her sister raise the chance of further use over the next 2 weeks. Overdose risk was high on Sunday: fentanyl, used alone, with no naloxone at hand. It stays raised while cravings are high. Suicide risk judged low: she used to numb distress, denies intent, has no past attempts, and has clear reasons to keep going. Goal 1, no opioid use: setback. Goal 2, a working relapse prevention plan: needs updating.
Relapse prevention plan updated together: if her ex-partner comes to the door, she won’t open it, will call her sister, and will go to her sister’s place if he stays. Second naloxone kit given for home, with how to use it reviewed; she agreed never to use alone. With her written consent, told the prescriber about the lapse and the cravings; dose review brought forward to Thursday. Counseling increased to twice a week for 2 weeks. Homework: tell her sister about Sunday, using the words practiced in session, and log each craving and what she did. Next session Friday, in person. She knows to call 911 for an overdose, and to call or text 988 for thoughts of suicide.
The lines at the top that place the session: when, how long, how, and what it was for.
Avoid: Leaving out the times. Start and end times show how long the session ran, and many organizations and payers ask for them.
The facts of the session: what the client told you, what you saw, what you measured, and what you did. A colleague sitting in the room could have written every line.
Avoid: Words that interpret, such as “resistant,” “improving,” or “in denial.” Write the behavior here, and put what it means in Assessment.
Your clinical thinking: what the data means. This is the part that shows your judgment, and the part most often left thin.
Avoid: Restating the Data in other words. If a sentence would sit comfortably under Data, it isn’t an assessment yet.
What happens next, and why. Each step should follow from something in the Assessment.
Avoid: A plan that ignores the Assessment. If you judged risk to be higher today, the Plan should show what you did about it.
“Client was resistant” is a judgment. Write what happened, such as “said the worry log was pointless and left 4 days blank,” and say what it means in Assessment.
“Client reports anxiety. Client is anxious.” adds nothing. Say what changed, why you think it changed, and what that means for treatment.
Name the goal that moved and the score, count, or behavior in Data that shows it, so the next reader doesn’t have to take your word for it.
Put what you asked and what the client said in Data, and your judgment of risk, with reasons, in Assessment. Either one alone leaves a gap.
“Continue weekly sessions” doesn’t say what you will work on. Add the homework, the next focus, and any change to care.
Vero Scribe writes the DAP note in your template from the session, with the client’s consent, or from your dictation afterward. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
DAP stands for Data, Assessment, and Plan. Under Data, write what the client said, what you observed, any scores, and what you did in the session. Under Assessment, say what that means: progress toward goals, how the client responded, and risk. Under Plan, write the homework, the next session’s focus, and any change to care. Write it the same day if you can.
Data is what anyone in the room could have seen or heard: the client’s words, your observations, scores, and the techniques you used. Assessment is your clinical judgment about those facts. “GAD-7 11, down from 16” is Data; “anxiety improving, now moderate” is Assessment. A quick test: if a line needs your training to write, it belongs in Assessment.
Most clinicians record them in Data, as part of what happened in the session, and judge the client’s response in Assessment. Some organizations add an interventions line under Plan instead. Either works if you do it the same way every time and name each technique.
SOAP splits the facts into Subjective, what the client reports, and Objective, what you observe and measure. DAP puts both under Data. Assessment and Plan are much the same in both. DAP is quicker for routine sessions; SOAP helps when you track symptoms and mental status closely.
Yes. Copy it, or download it as a Word or text file. No account needed.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
A CBT session in its own order: mood check, agenda, homework review, thought or exposure work, new homework, and feedback.
An EMDR session by phase: target, negative and positive cognitions, SUD and VOC, bilateral sets, closure, and reevaluation.
Goal, Intervention, Response, Plan: a progress note that opens with the treatment plan goal.
Behavior, Intervention, Response, Plan: a progress note that opens with what the client reported and what you saw.
One session written in all three formats, side by side.
The goals and objectives your Assessment tracks progress against.
Session notes drafted in your format, for you to review.
Notes for substance use care, from counseling to follow-up.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.