Free Mental Health Documentation Samples & Note Templates
See real examples of clinical notes for psychiatry, therapy, and behavioral health — then experience how ICANotes generates them in under two minutes.
Whether you're evaluating an EHR, training new staff, or simply looking for documentation examples to reference, this library gives you real-world samples of every major mental health note type. Browse examples of progress notes, SOAP notes, BIRP notes, psychiatric evaluations, discharge summaries, and more — then see how ICANotes makes creating them fast, compliant, and clinically thorough.
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What’s Inside the Library
What You’ll Find in the Sample Notes Library
This free resource includes clinical documentation examples and templates for behavioral health clinicians across psychiatric, therapy, nursing, case management, and substance use settings.
Psychiatric Initial Evaluation
Full intake documentation including present illness, chief complaint, mental status exam, DSM-5/ICD-10 diagnosis, and medication orders.
Psychiatric Progress Note
Med check and interval history formats for outpatient and inpatient settings.
Psychotherapy Progress Note
Individual session documentation with treatment plan alignment.
SOAP Notes
Psychiatric and psychotherapy versions using Subjective, Objective, Assessment, and Plan.
BIRP Notes
Behavior, Intervention, Response, Plan format used in behavioral health and substance abuse treatment.
DAP Notes
Data, Assessment, Plan format for counselors and therapists.
Group Therapy Notes
Documentation examples for group sessions.
Couples Therapy Notes
Session note formats for relationship counseling.
Nursing Notes
Behavioral health nursing documentation examples.
Case Management Notes
Progress and coordination notes for case managers.
Biopsychosocial Assessment
Comprehensive intake assessment with social, developmental, and family history.
Mental Status Exam
Standardized documentation of cognitive and psychiatric presentation.
Therapy Initial Assessment
Intake documentation for non-prescribing clinicians.
Outpatient Psychiatric Progress Note
Streamlined format for outpatient visits.
Substance Abuse Progress Notes
Inpatient and outpatient documentation examples.
Psychiatric Discharge Summary
Full discharge documentation with risk factors, diagnosis, and instructions.
Therapy Discharge Summary
End-of-treatment documentation for therapists.
Sample Initial Assessment Documentation
A complete initial assessment captures everything needed to establish a diagnosis, develop a treatment plan, and support billing compliance — all in one session. ICANotes structures this documentation so you never miss a required element.
Sample initial assessment elements include:
- Present illness and chief complaint
- Symptom documentation
- Past psychiatric, medical, and social history
- Developmental and family history
- Biopsychosocial assessment
- Mental status exam
- ICD-10 diagnosis (via drop-down menus organized by diagnostic category)
- Medication orders and patient recommendations (for prescribing clinicians)
- Therapy, suicide/violence risk assessment, and level of care justification (for non-prescribing clinicians)
- Automatic E/M code generation based on content and complexity
ICANotes generates a readable, complete narrative note from your clinical inputs — so your documentation reflects the thoroughness of your care.
Mental Health Progress Note Examples
Progress notes are the backbone of ongoing clinical documentation. They need to be thorough enough to support continuity of care and billing audits — but fast enough that documentation doesn't eat into clinical time.
With ICANotes, clinicians complete detailed progress notes in under two minutes using structured, click-to-chart templates that generate full narrative text automatically.
Progress note formats in the sample library:
- Psychiatric progress note (med check format)
- Psychotherapy progress note (individual therapy)
- Outpatient psychiatric progress note
- Couples therapy session note
- Group therapy session note
- Play therapy note
- Counseling session note
- Nursing progress note
- Case management progress note
Each sample shows how ICANotes documents interval history, mental status, clinical impressions, diagnoses, and recommendations in a format that's audit-ready and easy to read.
Psychiatric Progress Note
Psychotherapy Note
Psychiatric & Psychotherapy SOAP Note Examples
SOAP notes — Subjective, Objective, Assessment, Plan — are one of the most widely used formats in behavioral health documentation. A well-structured SOAP note gives any clinician who reviews the chart a clear, immediate picture of the patient's status and the plan of care.
ICANotes generates SOAP notes with the clinical depth required for psychiatric documentation: MSE data, medication status, diagnostic impressions, risk assessment, and treatment plan updates — all structured in the familiar SOAP format, completed in minutes.
BIRP Note Examples for Behavioral Health
BIRP notes — Behavior, Intervention, Response, Plan — are the standard documentation format in many behavioral health, substance abuse, and community mental health settings. They're designed to directly link clinical observations to treatment plan goals and demonstrate progress over time.
What each section of a BIRP note should include:
- Behavior: Direct observations and patient statements from the session, including relevant quotes
- Intervention: Specific methods, techniques, or therapeutic approaches used by the clinician
- Response: How the patient responded to interventions and measurable progress toward treatment goals
- Plan: Changes to the treatment plan, next steps, and scheduled follow-up
ICANotes includes structured BIRP note templates that guide documentation of all four components, connecting each session note to the active treatment plan automatically.
Psychiatric & Therapy Discharge Summary Examples
This module makes creating a discharge summary quick and easy.
A discharge summary is among the most consequential documents in a patient's chart — it captures the full clinical picture at the end of treatment and ensures continuity of care for the receiving provider.
ICANotes discharge summaries pull forward key data from the patient's chart, minimizing manual entry and reducing the risk of documentation gaps.
ICANotes discharge summary documentation includes:
- Cover page with findings from the initial psychiatric assessment
- All progress notes in compressed summary format (optional)
- Final page with patient risk factors, final diagnosis, condition at discharge, and discharge instructions
Sample discharge summaries in the library:
- Psychiatric discharge summary
- Therapy discharge summary
Psychiatry Discharge Summary
Therapy Discharge Summary
See How ICANotes Generates These Notes for You
The sample notes in this library show you what great behavioral health documentation looks like. ICANotes makes creating documentation like this the fastest part of your clinical workflow — not the most time-consuming.
Frequently Asked Questions About Mental Health Progress Notes
Learn what to include in behavioral health documentation and how common note formats differ.
More Resources on Writing Behavioral Health Notes
Valerie Barfield
APRN, GNP-BC, Sage Lifecare, Memphis, TN
"ICANotes creates a narrative note that is readable and thorough. I get lots of compliments on my documentation and I feel more confident in my coding.”
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