Note formats

14 note formats, each with a worked example.

Every format Tidemend drafts out of the box: what it's for, the sections it includes, and a short fictional example so you can see how it reads.

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Progress notes

Everyday session documentation, from classic SOAP to goal- and problem-oriented formats.

SOAPIndividual · Couples · Family
SOAP Note
The most widely used progress note. Separates what the client reported from what you observed, then your assessment and plan.
- Subjective
- Objective
- Assessment
- Plan
See format and example
DAPIndividual · Couples · Family
DAP Note
A compact format that merges subjective and objective information into a single Data section.
- Data
- Assessment
- Plan
See format and example
BIRPIndividual · Couples · Family
BIRP Note
Behavior-focused format popular in community mental health and with payers that want interventions spelled out.
- Behavior
- Intervention
- Response
- Plan
See format and example
GIRPIndividual · Couples · Family
GIRP Note
Starts from the treatment goal addressed, which keeps every note tied back to the plan.
- Goal
- Intervention
- Response
- Plan
See format and example
PIRPIndividual · Couples · Family
PIRP Note
Problem-oriented format: names the presenting problem first, then intervention, response and plan.
- Problem
- Intervention
- Response
- Plan
See format and example
SIRPIndividual · Couples · Family
SIRP Note
Situation-focused format that captures the context the client brought into the room.
- Situation
- Intervention
- Response
- Plan
See format and example
PIEIndividual · Couples · Family
PIE Note
Problem, Intervention, Evaluation. Short and outcome-oriented.
- Problem
- Intervention
- Evaluation
See format and example
NarrativeIndividual · Couples · Family
Narrative Progress Note
A flowing clinical summary with risk and plan, for clinicians who prefer prose over headings.
- Session Summary
- Risk Assessment
- Plan
See format and example
CouplesCouples
Couples Session Note
SOAP-style note for conjoint sessions that keeps each partner's perspective and the relational pattern visible.
- Subjective (each partner)
- Relational Dynamics Observed
- Interventions
- Assessment
- Plan
See format and example
FamilyFamily
Family Session Note
For family sessions with several participants: who attended, system dynamics and plan.
- Participants
- Reported Concerns
- Family Dynamics
- Interventions
- Plan
See format and example

Intake & assessment

First-session documentation that sets up the diagnosis and treatment plan.

IntakeIndividual · Couples · Family
Intake Assessment
First-session biopsychosocial assessment covering history, presenting problem, risk and initial diagnosis.
- Presenting Problem
- History of Present Concern
- Psychosocial History
- Mental Status Exam
- Risk Assessment
- Diagnostic Impression
- Initial Treatment Recommendations
See format and example

Specialty formats

Structured notes for EMDR, medication management and mental status exams.

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A therapist leaving her office in the evening light, smiling

14 note formats, each with a worked example.

Progress notes

SOAP Note

DAP Note

BIRP Note

GIRP Note

PIRP Note

SIRP Note

PIE Note

Narrative Progress Note

Couples Session Note

Family Session Note

Intake & assessment

Intake Assessment

Specialty formats

EMDR Session Note

Psychiatric Follow-up

Mental Status Exam

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Pick a format. Tidemend writes the first draft.