DAP 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]