Psychotherapy Progress Note (BIRP)

Date of Service: [Date of service]

Session Time: [Start time - End time / Total psychotherapy minutes] (Document per payer requirement.)

Service Type: [Individual / Couple / Family / Group]

Modality: [In-person / Telehealth-video / Telehealth-audio]

Participants Present: [Names and roles present]

Clinician: [Clinician name, credentials]

Behavior

[Client-reported concerns, symptom changes since last session, functional impacts, and recent stressors] (Use attribution language: "Client reports..."). [Clinician observations of presentation including affect, engagement, speech, psychomotor activity, and thought process] (Use attribution language: "Observed..."). (Write 1–2 brief paragraphs; include only session-relevant information.)

[Standardized measure name, score, and brief interpretation] (Include only if a measure was administered this session; otherwise omit this line.)

[Safety assessment summary] (Always include. If risk factors present, document SI/HI status, protective factors, and safety plan status. If negative, state: "Denies SI/HI; no safety concerns identified." If not formally assessed, state: "Risk not formally assessed this session" and document plan to address. Never omit safety documentation.)

Intervention

• [Therapeutic modality/framework used]
• [Specific interventions performed] (Use active verbs; specify techniques such as psychoeducation topic, skill taught, cognitive restructuring, exposure work, or mindfulness exercise.)
• [Rationale linking intervention to treatment goals or presenting symptoms]
• [Care coordination or collateral contact] (Include only if occurred; otherwise omit.)

Response

[Client engagement and receptiveness to interventions; observed or reported response; progress toward treatment goals or barriers encountered] (Write 2–4 sentences. Include brief direct quotes only when clinically meaningful.)

Plan

• [Next session focus] (1–2 focal areas.)
• [Homework/between-session tasks] (Make specific and measurable; if none assigned, state "No homework assigned.")
• [Session frequency]
• [Referrals or care coordination] (Include only if indicated; otherwise omit.)
• [Safety plan updates] (Include only if clinically indicated; otherwise omit.)

[Medical necessity statement linking ongoing symptoms/impairment to continued treatment need] (Include when documentation supports utilization review.)