How to write therapy session notes in India: SOAP, DAP and BIRP, with examples

Last updated 25 October 2026. The laws and codes quoted were read in their gazette or official copies on that date. This is an explainer, not legal advice; the practice advice is ours and is marked as such. Spotted a mistake? Write to hello@unifiedself.in and we will fix it and say so.

The short version

A session note has three jobs: what happened, what you made of it, and what comes next, written so that another clinician could pick up the work and you could stand behind every line. SOAP, DAP and BIRP are three ways of ordering the same material. Pick one and use it every time.
No Indian law prescribes a note format or a retention period for a solo counsellor or psychologist. The Mental Healthcare Act's confidentiality duty is the nearest binding rule; its record provisions are written for establishments and defined professionals.
The NCAHP's draft conduct regulations propose keeping records for three years from the last contact and supplying them within five working days. They are not in force. The data protection law's core duties start around mid-2027. Both tell you where practice is heading.
In the absence of an Indian rule, the most defensible retention policy is the one psychologists' bodies abroad use: seven years after the last session for adults, longer for minors. Write your policy down.

What a note is for

Most therapists write notes for themselves, which is why most notes are either three words or three pages. It helps to be clear about the readers a note may one day have. Yourself, before the next session, six months from now. A colleague who takes over if you fall ill. A supervisor. The client, who has a right to ask. An employer's insurer who needs a receipt and a dated record that sessions happened. A court, rarely, under an order. A good note serves all of them with the same text, which means it records facts and clinical reasoning and leaves out everything else.

Two kinds of writing get called notes, and keeping them apart solves half the problems. The progress note, or session note, is the record: date, duration, what the client brought, what you did, how they responded, risk, plan. Process notes are your working thoughts, hypotheses, counter-transference, the sentence you want to remember for supervision. The first is the file. The second is a tool, kept separately, and most careful practitioners destroy process notes once they have served their purpose. Everything below is about the progress note.

SOAP, DAP and BIRP, with examples

The three formats are templates for the same content. SOAP comes from medicine, from Lawrence Weed's problem-oriented record in the 1960s, and is the one most Indian training programmes teach. DAP and BIRP are mental-health adaptations used by community services in the United States, where a county manual will specify one or the other. None has a statutory status anywhere, and none is required in India. The choice is about which ordering matches how you think.

The examples below are for a fictional client, Maria Garcia, 29, seen online for exam-related anxiety ahead of a professional certification. Names and facts are invented.

SOAP: Subjective, Objective, Assessment, Plan

S: Maria reports "the panic came back on Tuesday" while studying; slept about five hours a night this week; says she has been avoiding the study table and scrolling instead. Denies thoughts of self-harm. Homework (worry diary) done on three of seven days.

O: Online session, 50 minutes, camera on. Speech rapid in the first ten minutes, settled after the breathing exercise. Able to name the catastrophic thought ("if I fail this I lose the job") and rate belief at 80 then 50 by the end.

A: Anxiety maintained by avoidance and all-or-nothing appraisal of the exam; sleep debt amplifying it. Engagement good; she used the diary when the structure was simple. No current risk indicators.

P: Continue weekly. Behavioural experiment: 25-minute study blocks with a timer, four this week, logged. Sleep window fixed at 11.30 to 6.30. Review belief rating next session. Next session Tuesday 7 pm.

SOAP separates what the client said from what you observed, which is its strength when a note may be read by others: a reader can see your evidence before your conclusion.

DAP: Data, Assessment, Plan

D: Reports return of panic on Tuesday while studying; five hours' sleep a night; avoiding the study table. Diary completed three days of seven. Speech rapid early in session, settled after breathing exercise. Named the catastrophic thought and re-rated belief from 80 to 50. Denies self-harm thoughts.

A: Avoidance and catastrophic appraisal maintaining the anxiety; sleep debt a contributor. Good engagement with structured tasks. No risk.

P: Weekly. Four timed 25-minute study blocks, logged. Fixed sleep window. Re-rate belief next session, Tuesday 7 pm.

DAP folds the subjective and objective into one Data section. It is faster and reads more naturally for talk therapy, where the line between reported and observed is often blurred. It asks slightly more of the reader to tell evidence from inference.

BIRP: Behaviour, Intervention, Response, Plan

B: Presented anxious, rapid speech; reports panic on Tuesday during study, avoidance of study table, about five hours' sleep nightly. Diary done three of seven days. Denies self-harm.

I: Paced breathing (four minutes); Socratic questioning of the thought "if I fail this I lose the job"; psychoeducation on avoidance and sleep; collaboratively designed a behavioural experiment with timed study blocks.

R: Settled within ten minutes; identified the thought and re-rated belief from 80 to 50; agreed to the experiment and the sleep window, chose her own timer app.

P: Weekly. Four 25-minute blocks, logged; sleep window 11.30 to 6.30; review next Tuesday 7 pm.

BIRP centres what you did and how the client responded, which is why services that must show their work to funders prefer it. For a therapist who wants a clear record of interventions across sessions, it is the most useful of the three.

Format	Best when	Weakness
SOAP	Notes may be read by other clinicians or an insurer; you want evidence separated from conclusion	The Objective section feels forced in talk therapy
DAP	Solo practice, fast writing, narrative therapies	Evidence and inference can blur
BIRP	Structured therapies such as CBT; you want interventions traceable over time	Can read like a procedure log if the client's words are left out

What belongs in every note

Whatever the format, the content checklist is stable. The American Psychological Association's 2007 record-keeping guidelines, which have no legal force in India but remain the most careful statement of the craft, say a psychologist "strives to maintain accurate, current, and pertinent records of professional services", and list what a record of each contact should hold: the date and duration, the type of service, the nature of the intervention, and a formal or informal assessment of the client's status. To that, add what Indian practice needs:

Date, start time and duration, and the mode: in person or online. For an insurer's receipt and for your own package arithmetic, the duration matters.
The client's words for what they brought, briefly and in quotation marks where the phrasing matters.
Your observations, stated as observations.
Risk: what you asked, what was said, what you did. "Denies thoughts of self-harm; no plan; protective factors noted" is one line and it is the most important line in the note on the day it matters.
Your assessment: the clinical reasoning, not a diagnosis unless you are qualified to make one and have made it.
The plan, including homework, the next session, and anything you agreed to do, a letter, a referral, a call.
Anything administrative that affects the record: a missed session and what was charged, a consent given or withdrawn, a request for records, information shared with a third party and the client's consent to it.

What does not belong: verbatim detail about third parties beyond what is clinically needed, speculation written as fact, your irritation, jokes, and anything you would not be able to explain to the client across the table. That is not a counsel of blandness. It is the test of a professional record.

The first-session note

The intake note carries more than any later one, because it establishes the baseline every later note is read against. Besides the ordinary content it should record the presenting problem in the client's words and when it began; relevant history, including prior therapy, medication and medical conditions; a risk screen with the answers; the client's goals; the therapy agreement, meaning fees, cancellation terms, confidentiality and its limits, and how you will communicate between sessions; and the client's consent, with the date. If a form captured any of this, note that the form exists and where. Our guide to cancellation policies covers the agreement part of that conversation.

What Indian law expects

Four instruments bear on a therapist's records in India. Read together, they add up to a duty of confidentiality, a right of access for the client, and a direction of travel on retention and data handling, but no format, no mandatory template and, for most counsellors, no statutory retention period yet.

The Mental Healthcare Act, 2017

The Act's confidentiality section is the one provision every therapist should know by heart:

All health professionals providing care or treatment to a person with mental illness shall have a duty to keep all such information confidential which has been obtained during care or treatment with the following exceptions, namely:— (a) release of information to the nominated representative … (b) release of information to other mental health professionals and other health professionals to enable them to provide care and treatment … (c) release of information if it is necessary to protect any other person from harm or violence; (d) only such information that is necessary to protect against the harm identified shall be released; (e) release only such information as is necessary to prevent threat to life; (f) release of information upon an order by concerned Board or the Central Authority or High Court or Supreme Court or any other statutory authority competent to do so; and (g) release of information in the interests of public safety and security.
Mental Healthcare Act, 2017, section 23(2).

Section 24(2) extends the right "to all information stored in electronic or digital format in real or virtual space", which covers WhatsApp threads and cloud notes. Section 25(1) gives the client "the right to access their basic medical records as may be prescribed", and section 25(2) lets the professional in charge withhold specific information only where disclosure would cause "serious mental harm" to the client or "likelihood of harm to other persons", in which case the client must be told of the right to apply to the Board.

Three limits on scope are worth knowing, because explainers often overstate the Act. Its duties attach to a "person with mental illness", which the Act defines as "a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life"; not every counselling client meets that. Its record-keeping machinery is built for a "mental health establishment", defined as a place "where persons with mental illness are admitted and reside at, or kept in", which an outpatient room or a video call is not. And its "mental health professional" is a psychiatrist, a professional registered with the State Authority under section 55, which registers "clinical psychologists, mental health nurses and psychiatric social workers", or an AYUSH postgraduate; a counselling psychologist is outside that list. The Act sets no retention period. Its spirit, confidentiality with narrow exceptions and access for the client, is nonetheless the standard an Indian court or complaint body would reach for, and we recommend practising as if section 23 applied to every client.

The RCI conduct regulations, 1998

For clinical psychologists on the Rehabilitation Council of India's register, the Rehabilitation Council of India (Standards of Professional Conduct, Etiquette and Code of Ethics for Rehabilitation Professionals) Regulations, 1998 apply. Regulation 13 is the record-keeping rule, and it is about fees as much as clinical content:

Maintenance of register, etc.—Every professional shall maintain the proper daily records of persons examined, the certificates, reports or prescriptions issued and the accounts of consultation fee, service charges and other charges recieved by him.
RCI (Standards of Professional Conduct, Etiquette and Code of Ethics for Rehabilitation Professionals) Regulations, 1998, regulation 13; the spelling is the gazette's.

Regulation 14 requires those records to be produced to the Council on demand; regulation 9 forbids a "No cure, No payment" contract and exorbitant fees; regulation 15 makes contravention grounds for removal from the register; and the declaration every registrant signs promises to "maintain and respect the secrets" of the profession. There is no retention period. The regulations bind RCI registrants only; our RCI guide explains who those are.

The NCAHP draft conduct regulations, 2026

On 27 April 2026 the National Commission for Allied and Healthcare Professions published for comment a draft of the Registered Allied and Healthcare Professionals (Professional Conduct and Ethics) Regulations, 2026, public notice M-13/4/2026-NCAHP. It is a draft. As of 25 October 2026 the Commission's regulations page lists only the registration regulations and the autonomous-boards regulations; the conduct regulations have not been notified. When they are, they will bind registered professionals, which will include psychologists once that register opens. The draft's record clauses:

Every Registered Allied and Healthcare Professionals, as per the Act, shall maintain medical records of patients for 3 years from the date of the last contact with the patient for treatment, in the standard format, as may be notified by the Commission, from time to time.
Draft regulation 10(a). Regulation 10(b) adds that records requested by the patient, an authorised attendant or a legal authority "shall be supplied within 5 working days"; 10(d) asks professionals to computerise records within three years of publication; 11 requires "signed documented informed consent" before clinical procedures; 13 keeps every communication with a patient confidential.

Three years from last contact is a shorter period than most psychologists' bodies recommend, and a "standard format" has not been published. Nothing in the draft prevents keeping records longer.

The Digital Personal Data Protection Act, 2023

Your notes are personal data about an identifiable person, and under this Act you are the "Data Fiduciary" responsible for them. The Act received assent on 11 August 2023; the Rules were notified on 13 November 2025. The commencement notification of the same date brings the operative sections, including those on consent and the duties of fiduciaries, into force "eighteen months from the date of publication", which lands around mid-May 2027. Until then the standards below are the law in waiting rather than the law in force, and the sensible course is to meet them now. Three provisions matter most for a therapist:

Consent, section 6(1): "free, specific, informed, unconditional and unambiguous with a clear affirmative action", for a "specified purpose" and "limited to such personal data as is necessary for such specified purpose". A consent form that says what you keep and why.
Security, section 8(5): "reasonable security safeguards to prevent personal data breach", including for processing by a Data Processor on your behalf, which is any software or cloud service you use. Rule 6 of the 2025 Rules spells the minimum out: encryption or masking, access control, backups, and logs kept for a year.
Erasure, section 8(7): personal data must be erased when consent is withdrawn or when "it is reasonable to assume that the specified purpose is no longer being served", unless "retention is necessary for compliance with any law for the time being in force". For a therapist that exception is the hinge: a written retention policy grounded in professional duty is what lets you keep a record after a client leaves.

The Rules' schedule of fixed erasure periods covers large e-commerce, gaming and social media platforms only; there is no health-records class. The Act does not tell a therapist how long to keep a file. It tells you to decide, write it down, and be able to justify it.

How long to keep notes

No Indian statute or notified professional rule sets a retention period for counselling or psychotherapy records. The reference points, with their limits:

Source	Period	Who it binds
NCAHP draft conduct regulations, 2026, reg. 10(a)	3 years from last contact	Nobody yet; a draft
Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, reg. 1.3.1	3 years, for indoor patients; records to be issued within 72 hours of request	Registered medical practitioners, not psychologists
APA Record Keeping Guidelines, 2007, guideline 7	"until 7 years after the last date of service delivery for adults or until 3 years after a minor reaches the age of majority, whichever is later"	US psychologists, as guidance; formally expired 2017 and not replaced

Our recommendation, marked as ours: keep the full record for seven years after the last session, and for a client who was a minor until three years after they turn eighteen, whichever is later; then destroy it securely and note the destruction. Seven years comfortably exceeds every Indian analogue, matches the longest-standing professional guidance, and is short enough to be defensible under the data protection law's purpose test. Write the period into your consent form, so that the client has agreed to it and the Act's "specified purpose" is on paper.

A system that survives a busy week

Everything above is undone by a note that never gets written. The habits that make writing happen, in our experience:

Write within 24 hours, ideally in the ten minutes after the session. Memory of a session halves overnight.
Use the same template every time, so the empty headings pull the content out of you. Three to six lines per heading is a complete note.
Dictate if typing is the obstacle. A phone's keyboard microphone turns two minutes of speech into a draft; tidy it into the headings afterwards. Speak as you would write the note, not as you would tell a colleague the story.
Keep process notes somewhere else, and date them, so that nothing speculative sits in the client's file.
Store the file as the law will soon require: behind a password, encrypted at rest, backed up, with access limited to you. A notebook meets none of those tests; a shared family laptop meets few. Whatever you use, know where every copy is.
Treat WhatsApp as part of the record. Scheduling messages are administrative, but a client who writes to you about their state between sessions has given you clinical information that belongs in the note. Summarise it there, and do not let the thread be the only copy.
Have an answer ready for the three requests: the client asking for their notes, which you honour in the spirit of section 25 and withhold only for the reasons in it; a supervisor, who sees a de-identified account; and a court or authority, which gets what an order requires and no more, after you have taken advice.

UnifiedSelf's notes follow this shape: a SOAP, DAP, BIRP or first-session draft from your dictated or typed bullets, a timestamp, attachments for a diary page or a report, and a store that the platform's own administrators cannot read. That is the one place this guide mentions the product. A disciplined notebook and a locked drawer served the profession for a century; the law is now asking for the lock to be digital.

Questions people ask

1. Which format should I use?

The one you will actually complete after every session. SOAP if your notes may be read by doctors or insurers; DAP if you want speed and a natural narrative; BIRP if you practise a structured therapy and want interventions traceable over time. Switching formats mid-file is worse than any of the three.

2. How long should a session note be?

Long enough that a colleague could continue the work from it and short enough that you will write it today. For a routine session that is 120 to 250 words. A first session, a risk event or a change of plan earns more.

3. Can I keep notes in a paper notebook?

Nothing in Indian law forbids it today. The data protection Act, once in force, expects "reasonable security safeguards" and the NCAHP's draft asks registered professionals to computerise records within three years of its publication. A notebook cannot be encrypted, backed up or access-logged, and it can be lost. If you keep paper, keep it locked, keep it alone, and plan the move.

4. Can my client read their notes?

The Mental Healthcare Act gives persons with mental illness a right of access to their basic medical records, and lets the professional withhold specific information only where disclosure would cause serious mental harm or endanger someone else. Even where the Act does not strictly reach your client, that is the standard to follow. Write every note as if the client will read it, and most access requests become easy.

5. How long must I keep notes in India?

No statute or notified rule says, for counsellors and psychologists. The NCAHP draft proposes three years from last contact and is not in force. We recommend seven years after the last session, longer for minors, written into your consent form; see the retention section for why.

6. What is different for a minor?

Consent comes from a parent or guardian, and the record should say whose. Keep the file longer, until at least three years after the client turns eighteen, because that is when they can first ask for it themselves. Be especially careful about what you record of family members' disclosures.

7. Do I need consent to keep notes at all?

Keeping a clinical record is part of providing the service, and the data protection law's consent requirement is about the purpose and scope of processing. The practical answer is a consent form at intake that says you keep session records, what they contain, who can see them, how they are stored and for how long. That one page satisfies the Mental Healthcare Act's spirit, the NCAHP draft's informed-consent clause and the data protection Act's "specified purpose" together.

Sources

Everything quoted on this page was read at its source on 25 October 2026. Government links change often, so we give the document names as well.

Mental Healthcare Act, 2017 (Act 10 of 2017): sections 2(1)(p), 2(1)(r), 2(1)(s), 23, 24, 25, 55 and 65. Gazette of India, Extraordinary, Part II, Section 1, 7 April 2017. egazette.gov.in.
Rehabilitation Council of India (Standards of Professional Conduct, Etiquette and Code of Ethics for Rehabilitation Professionals) Regulations, 1998: regulations 4, 9, 13, 14 and 15. Gazette of India, Part III, Section 4, 22 April 1998, as hosted by RCI under Acts and Rules. rehabcouncil.nic.in.
NCAHP, Draft Registered Allied and Healthcare Professionals (Professional Conduct & Ethics) Regulations, 2026, public notice No. M-13/4/2026-NCAHP, 27 April 2026: regulations 10, 11 and 13. ncahp.abdm.gov.in/DraftRegulations. Status checked against ncahp.abdm.gov.in/Regulations.
Digital Personal Data Protection Act, 2023 (Act 22 of 2023): sections 2(t), 6, 8(5), 8(7). egazette.gov.in. Commencement notification G.S.R. 843(E), 13 November 2025, egazette.gov.in. Digital Personal Data Protection Rules, 2025, G.S.R. 846(E), 13 November 2025: rules 1(4) and 6, and the Third Schedule. egazette.gov.in.
Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002: regulations 1.3.1, 1.3.2 and 7.14, as hosted by the National Medical Commission. nmc.org.in.
American Psychological Association, Record Keeping Guidelines, adopted February 2007: guidelines 2 and 7 and the expiration note. American Psychologist 62(9):993–1004. apa.org.
Weed LL. Medical records that guide and teach. New England Journal of Medicine 1968;278:593–600 and 652–657, the origin of the problem-oriented record from which SOAP derives.

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