SOAP Notes for DBT: Example and Template
Overview
This guide is part of our complete SOAP notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.
Want a first draft written from your session? The AI SOAP note generator in MentalNote turns a recorded session into a SOAP draft you review and edit.
No sign-up needed: open a fictional SOAP note in the MentalNote editor and edit it like a real draft.
Short answer: a DBT SOAP note puts the diary card review and the client’s report (urges, target behaviors, skills used, group and coaching use) in Subjective; your observations, ratings and the interventions delivered, such as a chain analysis or skills coaching, in Objective; your judgment about targets, progress and risk in Assessment; and homework, coaching agreements and next targets in Plan.
Individual DBT sessions follow a target hierarchy: life-threatening behaviors first, then therapy-interfering behaviors, then quality-of-life-interfering behaviors, with skills building throughout. Comprehensive DBT also includes a weekly skills group (mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness), between-session phone coaching and a therapist consultation team. Show which target the session addressed first and which components the client is receiving.
What to document in a DBT SOAP note
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Diary card: urges and target behaviors with counts and ratings | “Diary card complete 7 of 7 days. Urges to binge rated 3/5 on 3 days; one binge on Sunday. Suicidal thoughts 0/5 all week.” |
| Subjective | Skills used, group attendance and phone coaching | “Attended skills group (distress tolerance); used STOP twice; no coaching calls.” |
| Objective | Observations, ratings and the intervention used | “Chain analysis of Sunday’s binge; coached urge surfing and self-soothe; distress 7/10 to 4/10 in session.” |
| Assessment | Target addressed, links identified and progress toward goals | “Quality-of-life target; loneliness after a cancelled plan is the key link; binges down from 4 a week to 1.” |
| Assessment | Risk assessment when urges or life-threatening behavior are present | “Recent self-harm urges prompted a full suicide and self-injury risk assessment; see the worked note below for current thoughts, plan, intent, history, means, protective factors, risk formulation and safety actions.” |
| Plan | Homework, coaching agreement and next targets | “Daily diary card; urge surfing when urges reach 3/5; call for coaching before acting; review solution analysis.” |
If the diary card or session shows suicidal thoughts, self-harm or urges to act, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means, protective factors, your risk formulation and the safety plan. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document SOAP Notes for Dialectical Behavior Therapy
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section in DBT, capture the client's self-reported experiences including emotional states, presenting problems, triggering events, and mood fluctuations since the last session.
- Client's description of emotional distress or mood changes since the previous session
- Identification and narrative of specific triggers or stressors impacting emotional regulation
- Client's report on urges or episodes of maladaptive behaviors (e.g., self-harm, impulsivity)
- Description of interpersonal conflicts or relational difficulties as experienced by the client
- Self-reported success or challenges in using DBT skills outside of therapy
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
The Objective section for DBT should document observable clinician assessments, interventions delivered, and client engagement during the session.
- Clinician's observations of client's affect, body language, and level of distress during session
- Specific DBT skills taught or reviewed (e.g., mindfulness, distress tolerance) and client response
- Use of behavioral chain analysis or diary card review to identify patterns and reinforce skills
- Documentation of client’s ability to demonstrate or role-play DBT skills in session
- Application of validation techniques and client’s receptiveness to these interventions
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
In the Assessment section for DBT, summarize clinical impressions, evaluate client progress with treatment goals, and assess the effectiveness of therapeutic strategies applied.
- Clinical evaluation of client’s emotional regulation and distress tolerance improvements
- Assessment of client’s consistency and accuracy in using diary cards and self-monitoring tools
- Identification of barriers or challenges to skill acquisition and implementation
- Diagnostic clarification or updates based on session interactions and symptom report
- Client’s expressed motivation and readiness to engage in continued DBT treatment
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
The Plan section in DBT outlines upcoming therapeutic steps, targeted skill practice assignments, and any necessary treatment adjustments or referrals.
- Assignment of specific DBT homework tasks tailored to client’s current challenges
- Scheduling of next individual therapy session and coordination with group DBT if applicable
- Modification of treatment focus or goals based on recent client progress and needs
- Recommendations for additional support services or referrals (e.g., psychiatry, case management)
- Plan to reinforce or introduce new DBT modules or skills in upcoming sessions
DAP Notes for DBT
Alternative format for documenting dbt
BIRP Notes for DBT
Alternative format for documenting dbt
Progress Notes for DBT
Alternative format for documenting dbt
SIRP Notes for DBT
Alternative format for documenting dbt
GIRP Notes for DBT
Alternative format for documenting dbt
PIE Notes for DBT
Alternative format for documenting dbt
Example SOAP Note for DBT
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Subjective: Fictional adult client, individual DBT session 14, diagnoses borderline personality disorder (F60.3) and binge-eating disorder. Attends the weekly skills group (distress tolerance module; attended this week); no phone coaching calls this week. Diary card completed 7 of 7 days: suicidal thoughts 0/5 all week; self-harm urges 0–1/5; urges to binge rated 3/5 on 3 days; one binge on Sunday evening (4 a week at the start of treatment). Used the STOP skill twice, “and it worked on Friday.” Treatment-plan goals: (1) no self-harm; (2) binges no more than once a week; (3) keep weekly plans with friends.
Objective: On time, appropriately dressed; affect tearful when describing Sunday, then calmer. Speech normal; thought process logical. Agenda set by the target hierarchy: reviewed the recent self-harm urges and completed the risk assessment documented below before addressing the binge. No life-threatening behavior or therapy-interfering behavior reported this week; quality-of-life target then addressed. Completed a chain analysis of Sunday’s binge: vulnerability factors (skipped lunch, tired), prompting event (a friend cancelled dinner plans), thoughts (“nobody wants to see me”), loneliness and shame, then the binge. Solution analysis: coached urge surfing and self-soothe, and planned a text to another friend as an alternative at the point of loneliness. Rehearsed urge surfing in session; distress 7/10 at the start, 4/10 after.
Assessment: Binge frequency is improving (4 a week to 1) and the client is using distress tolerance skills between sessions. Loneliness after cancelled plans is the key link in the chain; skipping meals is a vulnerability factor. Goal 1 met for 10 weeks; goal 2 met this week; goal 3 in progress. Reviewed the diary card’s self-harm urges of up to 1/5 earlier this week; client reported that these passed without acting. Asked directly: denied current suicidal thoughts, suicidal plan or intent, preparatory behavior, current self-harm urges, and intent to self-harm. Reported no prior suicide attempts; previous self-injury was without suicidal intent, most recently 10 weeks ago. Denied firearm access; medications and previously used self-harm items are secured by a support person under the agreed means-safety plan. Protective factors include engagement in DBT, successful skills use and an available support person. Acute suicide risk assessed as low on these findings; recent urges and self-injury history indicate continuing risk of self-injury requiring active monitoring. Reviewed the safety plan, means-safety arrangements and escalation contacts; the client named their first three steps. Continue outpatient DBT with reassessment at the next contact and sooner if urges recur or intensify.
Plan: Continue weekly individual DBT, skills group and phone coaching as agreed. Homework: daily diary card; urge surfing when binge urges reach 3/5; regular meals using PLEASE skills; text a friend when plans are cancelled; call for coaching before acting on urges. Next session: review the solution analysis and diary card. If suicidal thoughts or self-harm urges return, the client will follow the safety plan, use phone coaching and call or text 988; for imminent danger, 911.
See a note like this in the editor: open a prepared fictional SOAP note in MentalNote, no sign-up. For your own sessions, the AI SOAP note generator drafts the note from a recorded session for you to review and edit.
Tips for SOAP Notes for Dialectical Behavior Therapy
1. Start from the diary card
Record urges, target behaviors and skills used with counts and ratings, so weeks can be compared.
2. Show the target hierarchy
State which target the session covered first, even when there was no life-threatening behavior to address.
3. Keep the chain analysis short
Record vulnerability factors, prompting event, key thoughts and emotions, the behavior and the solutions agreed, not the whole chain.
4. Name skills and modules
For example “urge surfing,” “STOP (distress tolerance)” or “DEAR MAN (interpersonal effectiveness),” and whether each was taught, coached or practised.
5. Record group and coaching use
Note skills group attendance and phone coaching, so the record shows which DBT components the client is receiving.
6. Document risk every session
Record the suicide and self-harm screen from the diary card and in session, and the full assessment when urges are present.
Master SOAP Notes Documentation
Let AI handle the structural formatting and organization while you focus on what matters: your clinical work and client care. Mental Note AI drafts properly formatted notes for you to review, in the web app or in Microsoft Word.
Try a sample SOAP note, no sign-upReady for your own sessions? Create a free account: 5 web-app scribe sessions a month, BAA included, no credit card.
Prefer Microsoft Word? Get the free Word add-in. Installs from Microsoft AppSource.
Ready to Write Better Notes Faster?
Mental Note AI drafts structured clinical notes for you to review and edit.
Try it freePrefer Microsoft Word? Get the free Word add-in. Installs from Microsoft AppSource.
No credit card required. Works directly in Microsoft Word. You review and edit every draft.
Further Reading
- APA Documentation Guidelines — Provides detailed standards for clinical documentation relevant to psychological therapies including DBT.
- SAMHSA — Offers resources and best practices for behavioral health documentation and treatment planning.
- DSM-5-TR — Essential for accurate diagnosis and clinical terminology used in mental health documentation.