All examples on this page are fictional composites. They do not describe real clients.
1. Depression, individual, in person
Adult client in their 50s, session 8, 50 minutes. Treatment goal 1: return to two social activities a week.
S: Client reports mood "a bit better, maybe a 5 out of 10" (was 3 at intake).
Went to a community choir rehearsal for the first time in a year and "felt
awkward but stayed." Still waking at 4 a.m. most days. Skipped the second
planned activity. Denies suicidal ideation.
O: Neatly dressed, good eye contact. Speech normal. Affect mildly constricted,
brighter when describing the choir. PHQ-9: 12 (was 19 at intake); item 9
(thoughts of death or self-harm): 0.
A: Improving depressive symptoms, supported by the PHQ-9 change and the
client's report. Reviewed the activity log and scheduled two activities for
the coming week. Behavioral activation is helping; the client completed one of
two planned activities and named avoidance ("I'll go next week") as the
barrier to the second. Early waking persists. Partial progress toward goal 1.
No risk indicators today.
P: Continue behavioral activation; plan two activities with specific days and
times. Add a sleep routine (fixed wake time, no lying in bed awake over 20
minutes). Client to raise early waking with their prescriber at next week's
appointment. Next session in one week.Why it works: the Subjective uses the client's own rating, the Objective has a measure and an observation, and the Assessment explains the change against the goal rather than repeating it.
2. Trauma symptoms, individual, telehealth
Adult client in their 20s, session 4, 50 minutes. Treatment is in a stabilization phase. Treatment goal 1: use a grounding skill on their own when symptoms spike.
S: Client reports two nightmares this week and "jumping out of my skin" when a car alarm went off near their apartment. Used the 5-4-3-2-1 grounding exercise once and "it took the edge off." Sleeping about 5 hours. Denies suicidal ideation and thoughts of self-harm. Reports feeling safe at home. O: Video session; client confirmed they were at home. Alert, oriented. Hypervigilant: looked off camera several times at sounds. Affect anxious, became calmer during the grounding practice. PCL-5: 48 (was 52 two weeks ago). A: Ongoing trauma-related symptoms, including intrusions, hyperarousal and sleep disruption. Client is building grounding skills and used one on their own this week, early progress toward goal 1. Not yet ready to begin trauma processing, since grounding is not yet used consistently; client agrees to keep building coping and safety first. Low risk today based on client report and presentation. P: Practice grounding daily and add a bedtime wind-down routine. Next session: psychoeducation on the stress response and a calm-place exercise. Review nightmares and sleep at each session. Next session in one week.
Why it works: it records symptom patterns without retelling the trauma itself, and the Assessment explains the clinical decision about pacing.
3. Grief, individual, in person
Adult client in their 60s, session 3, 50 minutes. Treatment goal 1: keep up daily routines, including regular meals.
S: Client's spouse died four months ago. Client reports "waves" of sadness, most often in the evenings, and has not opened the spouse's mail. Sees grandchildren weekly and says those visits help. Eating one main meal a day. Denies suicidal ideation; says "I want to be here for the kids." O: Tearful at several points, able to continue. Speech normal. Engaged; brought a photo to share. Thought process linear. A: Grief response that appears consistent with recent loss. Explored the client's memories of their spouse and what makes the mail hard to open. Client is connecting with family and expressing grief openly, both strengths. Reduced eating means limited progress toward goal 1. Avoidance of the spouse's mail is an area to monitor. No indicators of risk; family connection is a protective factor. P: Continue grief-focused therapy. Client chose to open the mail with their daughter this week. Encourage a second daily meal. Monitor appetite and avoidance over the next sessions. Next session in two weeks.
Why it works: the Assessment notes strengths and protective factors, not only symptoms, and the Plan uses the client's own choice of next step.
4. Family session with a teenager, in person
Adolescent client, 14, with a parent, session 5, 60 minutes. Treatment goal 2: reduce arguments about schoolwork.
S: Teen reports "less yelling this week." Parent reports two arguments about homework, down from daily. Teen says the after-school break before homework "helps." Parent worried about a math grade. O: Teen sat with arms crossed for the first 10 minutes, then joined the discussion. Parent spoke over the teen twice; both used the agreed pause signal once, with prompting, during a disagreement in session. A: Conflict frequency is down, which supports the homework routine agreed in session 3. Both can use the pause signal when prompted. Parent anxiety about grades may be driving some escalation. Progress toward goal 2. No safety concerns reported or observed. P: Keep the after-school break and homework routine. Parent to try one "check-in without correcting" each day. Individual time with the teen for the first 15 minutes next session, as agreed with both, including a check on mood and safety. Before it, review with both what stays private and what would be shared with the parent, such as safety concerns. Next session in one week.
Why it works: it records both people's view, describes behavior rather than labelling it, and keeps the plan specific to each person.
What these examples have in common
- The Subjective uses the client's words and ratings.
- The Objective has at least one observation and, where available, a measure.
- The Assessment links today to a treatment goal and says what the change means.
- Risk is recorded every time, including when there is none.
- The Plan names the intervention, the homework and the next appointment.
FAQ
What is a good SOAP note example for mental health?
One where another clinician could tell what the client reported, what you observed, what you concluded and what happens next. The examples above each tie the Assessment to a treatment goal and record risk.
How do you write the Objective section in a therapy SOAP note?
Record what you observed and measured: appearance, affect, behavior, engagement and any scores. Avoid conclusions in this section; they belong in the Assessment.
Should a SOAP note describe trauma in detail?
Usually not. Record symptoms, the work done and the client's response. Detailed trauma narratives are rarely needed in a progress note and can expose the client if records are shared.
Can I use SOAP notes for family or couple sessions?
Yes. Record each person's report and your observations of the interaction. Follow your setting's rules on whose record the note goes in. With a minor client, also check your state's rules on what a parent can see in the record.
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.