Counseling and therapy SOAP note example

A progress note for an individual therapy session with an adult client treated for generalized anxiety disorder with CBT. It records what the client reports, the mental status and a standardized score, the risk assessment, and a plan with homework.

Example SOAP note

Fictional client: Maya R., 29, sixth session of weekly individual therapy, 53 minutes, in office. Any likeness to a real person is a coincidence.

Subjective

Client reports anxiety at "about a 6 out of 10 most days" this week, down from 8 at intake. Sleeping about 6 hours a night; woke at 3 a.m. with worry twice this week.

Used box breathing before a team presentation on Tuesday and "got through it without leaving the room." Still avoids highway driving; took side roads to work every day.

Completed 4 of the 5 thought records assigned. Taking sertraline 50 mg daily as prescribed by her primary care provider; reports no side effects.

Denies suicidal ideation, intent or plan, and denies thoughts of harming others.

Objective

On time, casually dressed, good hygiene. Alert and oriented x4.

Speech normal in rate and volume. Mood "a bit better"; affect anxious but brighter than last session, congruent with content. Thought process linear and goal-directed; no evidence of psychosis.

GAD-7: 11 today (14 at intake, four weeks ago).

Engaged throughout. Fidgeting with her sleeve in the first half, which eased while practicing breathing.

Interventions: reviewed thought records, cognitive restructuring of "I'll panic and crash" on the highway, psychoeducation on avoidance and anxiety, introduced an exposure hierarchy.

Assessment

Generalized anxiety disorder (F41.1), improving. GAD-7 down 3 points, now in the moderate range. Client is using breathing and cognitive restructuring outside sessions; highway avoidance is the main behavior keeping the anxiety going.

Goal 1 (GAD-7 below 10): progressing. Goal 2 (drive one highway exit without leaving): not yet started.

Risk: low. No suicidal ideation; protective factors include her partner, stable work and engagement in treatment.

Continues to need weekly outpatient therapy to build exposure skills.

Plan

Continue weekly 53-minute individual CBT sessions.

Next session: finish the exposure hierarchy; first step is one highway exit on a weekend morning with her partner in the car.

Homework: thought records 3 times a week, box breathing daily, and rate anxiety 0–10 before and after each practice.

Repeat GAD-7 in four weeks.

Safety plan reviewed: client will call or text 988, or go to the nearest emergency room, if thoughts of self-harm come up.

With the client's written consent on file, update her primary care provider on progress.

Next appointment in one week.

Why this note works

  • The client's own words are quoted where they carry meaning ("got through it without leaving the room").
  • A standardized measure (GAD-7) is compared with intake, so progress is visible without reading earlier notes.
  • Risk is assessed and documented at every session, with protective factors and a safety plan.
  • The Assessment ties each goal to a status, and the Plan says what happens next session and when the measure is repeated.
  • The interventions are named, which shows what the session was and supports medical necessity.

What to include in each section

Subjective

  • Presenting concerns this week, in the client's words
  • Mood, sleep, appetite and stressors since the last session
  • Homework or skills practiced, and how it went
  • Medication changes and side effects
  • Suicidal or homicidal ideation, intent or plan (asked and answered)

Objective

  • Mental status: appearance, orientation, speech, mood and affect, thought process
  • Standardized scores (PHQ-9, GAD-7, PCL-5) with the last result
  • Behavior and engagement in session
  • Interventions used (CBT, DBT skills, EMDR, motivational interviewing…)

Assessment

  • Diagnosis (ICD-10-CM) and whether symptoms are improving, stable or worse
  • Progress toward each treatment-plan goal
  • Risk level and protective factors
  • Medical necessity for continued therapy

Plan

  • Session frequency and length
  • Focus of the next session
  • Homework
  • Safety plan, if risk was identified
  • Coordination with prescribers or other providers (with consent)
  • Next appointment

Write yours with the free SOAP note template

The template opens with the counseling prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

Try CloudMedico free for 30 days

More SOAP note examples

Questions

What's the difference between a progress note and psychotherapy notes?

A progress note like this one goes in the client's record and supports billing. Psychotherapy notes are a therapist's separate process notes about the session's content; HIPAA gives them extra protection, and they are kept apart from the record.

Do I need to document risk in every therapy note?

Asking about and recording suicidal and homicidal ideation at each session is widely expected practice, and it protects the client and you. When risk is present, record the level, protective factors and the safety plan.

Should a therapy SOAP note include the diagnosis code?

If you bill insurance, yes: the Assessment should name the diagnosis the services treat, usually with its ICD-10-CM code, and say how the client is responding.

Sources

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