Therapy DAP Notes Template

Description:

This template employs the DAP (Data, Assessment, Plan) framework to document general therapy sessions, offering a concise yet comprehensive structure for therapists to record client data, clinical evaluations, and treatment plans. It is designed for ongoing sessions to track progress and guide therapy, with detailed guidance within brackets to support thorough and professional note-taking for continuity and clarity.

Note:

This template is intended for regular therapy sessions following an initial intake. Adjust sections as needed based on the session’s focus, client presentation, or therapeutic approach.

Date: [Record the date of the therapy session to maintain an accurate chronological record of the client’s treatment history]

Client Name: [Enter the client’s full legal name to ensure proper identification and consistency across all session documentation]

Therapist Name: [Enter the therapist’s full name to establish accountability and authorship of the notes]

Session Number: [Note the session number in the sequence of therapy to provide context for tracking the client’s progress over time]

Data

Client’s Subjective Report: [Document the client’s self-reported experiences, emotions, symptoms, or events since the last session, capturing their perspective in their own words where possible, to reflect their subjective state and concerns.]
Therapist’s Objective Observations: [Record observable details about the client’s presentation, such as behavior, mood, affect, or non-verbal cues like posture or facial expressions, to provide an objective account of their in-session demeanor.]
Interventions Applied: [Detail the specific therapeutic techniques or strategies used during the session, such as guided imagery, cognitive reframing, or open-ended questioning, including their purpose and context, to catalog the actions taken to address the client’s needs.]

Assessment

Therapist’s Clinical Evaluation: [Summarize the therapist’s professional interpretation of the client’s current condition, integrating subjective reports and objective observations, to assess their psychological state, challenges, or emerging patterns.]
Progress Toward Goals: [Evaluate the client’s advancement toward their therapy goals, noting specific improvements, obstacles, or areas requiring further attention, to gauge the effectiveness of the current treatment approach.]
Risk Assessment: [Document any indications of risk, such as suicidal thoughts, self-harm tendencies, or harm to others, including severity, intent, and protective factors, to ensure safety is actively monitored and addressed.]

Plan

Next Steps for Therapy: [Outline the intended focus, topics, or interventions for the upcoming session, such as exploring a new issue or building on today’s work, to provide direction and maintain therapeutic momentum.]
Homework or Tasks Assigned: [List any assignments or activities given to the client to complete before the next session, including their purpose—like practicing a skill or reflecting on a topic—to reinforce in-session gains and promote active engagement.]
Adjustments to Treatment: [Note any planned changes to the overall treatment strategy, such as shifting modalities or involving additional resources like a referral, to adapt the plan based on the session’s insights.]

Additional Notes

[Include any supplementary details not covered in the DAP sections, such as logistical updates (e.g., scheduling conflicts), client questions, or external factors influencing the session, to ensure a complete record of relevant context.]