SOAP Note Assessment Examples for Therapists

What the Assessment section does

The Subjective and Objective sections record what happened. The Assessment interprets it. A useful Assessment usually covers four things:

1. Clinical impression of today. What the client's report and your observations suggest.
2. Progress toward goals. Where the client is against the treatment plan, with the evidence.
3. Response to interventions. How the client responded to the work in session, and what that tells you.
4. Risk. Your assessment of risk and the reasoning, including when risk is low.

If you bill insurance, your payer may expect the record to show why continued treatment is needed. The Assessment is the natural place for that reasoning. Check your payer's own documentation guidance.

Diagnostic impressions can appear here too, but only within your license's scope.

Five weak and strong examples

All examples on this page are fictional composites. They do not describe real clients.

1. Anxiety, session 6

Weak:

A: Client is anxious. Session went well.

Strong:

A: Worry about work performance remains the main driver of anxiety; GAD-7 fell
from 15 to 11 since intake. Client identified rehearsal as a safety behavior
when prompted and generated one alternative, which suggests growing awareness
of how safety behaviors maintain worry. Progress toward goal 1 (reduce daily
worry time). No risk indicators reported or observed today.

Why: the strong version names the pattern, gives evidence of change and ties it to a goal.

2. Depression, session 10

Weak:

A: Client reports feeling a bit better. Continue treatment.

Strong:

A: Depressive symptoms improving (PHQ-9 down from 18 to 12), with gains linked
to increased activity. Progress toward goal 1 (resume daily activities), but
social withdrawal persists on weekends, when structure is lowest. Client
engaged with activity scheduling and described the link between activity and
mood in their own words. Continued treatment is indicated to address weekend
withdrawal and sustain gains. Denies suicidal ideation; low risk.

Why: it explains what is improving, what is not and why treatment continues.

3. Couple, session 4

Weak:

A: Couple argued in session. Communication is poor.

Strong:

A: Conflict follows a pursue-withdraw cycle: one partner raises concerns
quickly, the other leaves the conversation. With structure, both partners
could summarize each other's view, which suggests the pattern can shift with
practice. Partial progress toward goal 2 (resolve one disagreement a week
without leaving the room). No safety concerns reported when asked separately.

Why: it describes the interaction pattern instead of judging it, and records that safety was checked.

4. Adolescent, session 3

Weak:

A: Teen was defiant and unmotivated.

Strong:

A: Teen was guarded early in session and engaged once the topic shifted to
music, which suggests rapport is still forming. School avoidance appears linked
to social anxiety at lunch rather than academic difficulty. Attended 3 of 5
school days this week toward goal 1 (attend five school days a week); too early
to judge a trend. No risk indicators; teen denies suicidal thoughts and
self-harm when asked alone.

Why: "defiant" and "unmotivated" are labels. The strong version describes behavior and offers a working hypothesis.

5. Passive suicidal ideation, session 7

Weak:

A: Client has SI. Safety plan done.

Strong:

A: Client reports passive suicidal ideation without plan or intent, increased
since a job loss two weeks ago. No access to firearms; no history of attempts.
Protective factors: close friend, engagement in treatment, future-oriented
statements about a planned trip. Risk assessed as elevated from baseline but
not imminent. Safety plan updated in session, including the 988 Suicide &
Crisis Lifeline, and session frequency increased to twice weekly. Goal 1
(return to a daily routine) paused this week while safety is the focus.

Why: it records what was assessed, the factors in both directions, the conclusion and the reasoning behind the actions in the Plan. Follow your setting's risk-assessment protocol.

Common mistakes

1. Repeating the Subjective. "Client reports feeling anxious" is a report. Say what the anxiety means for treatment.
2. Labels instead of observations. "Resistant", "manipulative" and "noncompliant" read as judgments. Describe what happened.
3. No goal named. Each Assessment should say where the client is against at least one goal.
4. Risk left out when it is low. A short "denies suicidal ideation; low risk" still belongs in the note.
5. Signing a draft you did not reason through. If you start from a draft or last week's note, read every line and rewrite anything that does not match your clinical judgment.

FAQ

What goes in the Assessment section of a SOAP note?
Your clinical interpretation of the session: what the client's report and your observations mean, progress toward treatment goals, response to interventions and your assessment of risk.

Can the Assessment include a diagnosis?
Diagnostic impressions can appear in the Assessment if diagnosing is within your license's scope. Changes to a diagnosis should be supported by what you documented.

How long should the Assessment be?
Often three to six sentences for a routine session. It should be long enough to show your reasoning, not a summary of the whole session.

What is the difference between the Assessment and the Plan?
The Assessment says what is happening and why. The Plan says what you and the client will do next.

For more filled notes, see the SOAP note examples for mental health.

This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.