SOAP Note Template for Therapists: Examples & Writing Guide

What Is a SOAP Note?

A SOAP note is a structured progress note format used across healthcare, including mental health settings. SOAP stands for Subjective, Objective, Assessment, and Plan — four sections that organize clinical observations into a logical, defensible record of care.

Originally developed for medical settings, the SOAP format has become one of the most widely used documentation methods in psychotherapy because it creates a clear, standardized record that satisfies insurance requirements, supports clinical decision-making, and provides legal protection.

When You Need It

• After every individual, couples, or family therapy session
• When insurance requires structured progress notes for reimbursement
• When your employer, agency, or supervisor mandates the SOAP format
• When transferring care to another provider who needs to review your notes
• When documentation may be subject to legal review or audit

Key Components of a SOAP Note

S — Subjective

What the client reports. This includes their own words about symptoms, mood, stressors, and experiences since the last session. Use direct quotes when clinically relevant.

Include:

• Client's self-reported mood and symptoms
• Events or stressors discussed
• Sleep, appetite, and medication changes the client reports
• Direct quotes that capture clinical significance
• Client's perspective on progress

O — Objective

What you observe directly. This is your clinical observation — the client's presentation, behavior, affect, and engagement during the session.

Include:

• Appearance, behavior, and psychomotor activity
• Affect and mood as observed (not just reported)
• Speech, thought process, and cognitive functioning
• Engagement and participation level
• Results of any screening measures administered (PHQ-9, GAD-7, etc.)
• Interventions used during the session

A — Assessment

Your clinical interpretation. This is where you synthesize the subjective and objective data into a professional judgment about the client's current status and progress.

Include:

• Clinical impressions and formulation
• Progress toward treatment plan goals
• Risk assessment (suicidal ideation, self-harm, harm to others)
• Changes in diagnosis or severity
• Response to interventions
• Barriers to progress

P — Plan

What happens next. This section documents the plan for ongoing treatment, including any changes to the treatment approach.

Include:

• Next session date and frequency
• Interventions to continue or modify
• Homework or between-session tasks
• Referrals made or recommended
• Medications discussed (if applicable)
• Any coordination of care planned

Filled-In SOAP Note Example

How to Write a SOAP Note Step by Step

Step 1: Write the Objective section first. While it seems counterintuitive, starting with what you observed grounds your note in facts. Document the client's presentation, your clinical observations, and any measures or interventions used.

Step 2: Write the Subjective section. Capture what the client reported in their own words. Focus on clinically relevant information — not a transcript of the session.

Step 3: Write the Assessment. Synthesize the S and O sections into your clinical judgment. This is where your expertise matters most. Address progress toward goals, risk, and treatment response.

Step 4: Write the Plan. Document next steps clearly. Anyone reading this note should know what you intend to do next and why.

Step 5: Review for the "Golden Thread." Check that your note connects the client's presenting problem → diagnosis → treatment plan goals → session interventions → progress. This connection is what insurance auditors and clinical reviewers look for.

Common Mistakes

1. Putting clinical opinion in the Subjective section. The S section is for the client's words, not your interpretation. "Client appears anxious" belongs in Objective, not Subjective.

2. Writing vague Assessments. "Client is progressing" tells a reader nothing. Specify how — "PHQ-9 decreased from 16 to 12; client completed avoided tasks for the first time in 3 weeks."

3. Omitting risk assessment. Every note should briefly address risk, even if it's "Client denied SI/HI; no current safety concerns identified." Omitting this creates liability.

4. Including too much session content. Progress notes are not session transcripts. Document what's clinically relevant, not everything that was said. Remember that psychotherapy notes (detailed process notes) are separate from progress notes under HIPAA.

5. Forgetting the Plan section. A note without a plan suggests aimless treatment. Always document next steps, even if the plan is simply "continue current treatment approach."