The template
Client: [identifier your setting uses] Date of service: [date] Start and end time: [00:00 to 00:00] Session type: [individual / couple / family / group; in person or telehealth] Telehealth (optional): [client's location this session; video or audio only] Service code: [if you bill] Clinician: [name, credentials] Diagnosis (optional): [from your treatment plan, if applicable] S (Subjective) - Client's report this session, in their words where useful: [ ] - Changes since last session (symptoms, sleep, functioning, events): [ ] - Homework or between-session practice, as reported: [ ] - Risk as reported by the client (thoughts of suicide, self-harm or harm to others): [ ] O (Objective) - Observed presentation (appearance, behavior, affect, speech, thought process): [ ] - Measures given and scores: [ ] - Engagement and participation in session: [ ] - Risk-relevant observations: [ ] A (Assessment) - Your clinical interpretation of today's session: [ ] - Progress toward treatment-plan goals: [ ] - Interventions used today and the client's response: [ ] - Risk level and your reasoning: [ ] P (Plan) - Interventions for next session: [ ] - Homework or practice agreed: [ ] - Referrals, coordination or safety-plan updates: [ ] - Next appointment and frequency: [ ] Signature, credentials, date: [ ] Supervisor co-signature (if required): [ ]
What goes in each section
Subjective is what the client tells you. Their concerns, how the week went, what they noticed, what they practiced. A short direct quote can carry a lot: "I didn't leave the house on Saturday." Keep your interpretation out of this section.
Objective is what you observe and can measure. How the client presented, their affect, speech and engagement, and any scores from measures you gave in session (for example a PHQ-9 or GAD-7 total). Write observations, not conclusions: "tearful when discussing their father" rather than "grieving".
Assessment is where your clinical thinking goes. Tie the Subjective and Objective material to the treatment plan: what changed, what it suggests, which interventions you used and how the client responded, and where they are against their goals. If risk came up, record your assessment of it and why you reached it.
Plan is what happens next. Interventions you intend to use, homework agreed with the client, referrals or coordination, any safety-plan changes and the next appointment.
A filled example
All examples on this page are fictional composites. They do not describe real clients.
An adult client in their 30s, seen weekly for generalized anxiety, session 6, telehealth, 50 minutes.
S: Client reports "a calmer week" and two nights of better sleep. Says the worry spiked Thursday before a work review and they "spent an hour rehearsing every possible question." Completed the worry log on 4 of 7 days. Denies thoughts of suicide, self-harm or harm to others. O: Alert, casually dressed, on time. Speech normal in rate and volume. Affect anxious early in session, brighter by the end. Engaged throughout; brought the worry log to session. GAD-7: 11 (was 15 at intake). A: Worry remains high around performance evaluation, with rehearsal used as a safety behavior. Reviewed the worry log and used Socratic questioning; client identified the rehearsal as avoidance and generated one alternative response. The GAD-7 change and reported calmer week suggest progress toward goal 1 (reduce daily worry time); log completion shows engagement with homework. No risk indicators reported or observed today. P: Continue CBT. Introduce scheduled worry time and one behavioral experiment: limit review prep to 20 minutes and record the outcome. Keep worry log. Next session in one week, same time.
For more filled SOAP notes, including different presenting concerns, see the SOAP note examples for mental health.
Common mistakes
- Interpretation in the Subjective section. "Client is in denial" is an assessment. Put the client's words in S and your reading of them in A.
- Vague Objective notes. "Client presented well" tells the next reader nothing. Name what you saw: affect, engagement, any scores.
- An Assessment that repeats the Subjective. The Assessment should add your reasoning, not restate what the client said.
- No link to the treatment plan. Each note should show where the client is against at least one treatment goal.
- Risk mentioned but not assessed. If suicide, self-harm or harm to others came up, the note should show what you asked, what you concluded and what you did.
- A Plan with no next step. "Continue therapy" is not a plan. Name the intervention, the homework and the next appointment.
SOAP, DAP or BIRP
SOAP separates what the client says from what you observe. DAP combines those two into one Data section. BIRP organizes the note around the intervention you used. Use the format your setting, supervisor or payer expects. For a side-by-side guide, see SOAP notes format for therapists.
FAQ
Is there one required SOAP note format for therapists?
No. SOAP is a widely used structure, not a single mandated form. Your licensing board, agency, supervisor or payer may require particular fields, such as start and end times or a diagnosis code. Check their requirements and adjust the template.
Where do test scores go in a SOAP note?
In the Objective section, with the measure's name and the score. Your interpretation of the score, such as what a change since intake suggests, goes in the Assessment.
Where does suicide risk go in a SOAP note?
It can appear in each section. What the client reports goes in Subjective, what you observe in Objective, your risk assessment and reasoning in Assessment, and safety-plan steps in Plan. Follow your setting's risk-assessment protocol. A safety plan usually lists crisis contacts, such as the 988 Suicide and Crisis Lifeline in the US.
How long should a SOAP note be?
Long enough that another clinician could understand what happened, why you did what you did and what comes next. For many routine sessions that is a short paragraph per section.
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.