Therapy Session SOAP Notes
A behavioral-health SOAP progress note — clinician and client, session details, Subjective / Objective (mental status & engagement) / Assessment (progress toward goals, risk) / Plan (interventions, homework, next session, safety), and signature.
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THERAPY SESSION PROGRESS NOTE (SOAP)
Clinician: Dr. Sam Reyes, LCSW
Client: A.M. Date: June 19, 2026
Session 8 · individual · 50 min · telehealth
Dx: F41.1 Generalized anxiety disorder
S — SUBJECTIVE
Client reports improved mood over past week (anxiety 4/10, down from 7). Sleeping ~6.5 hrs. Used breathing skills before a work presentation "and it helped." Continued tension with sibling; feels "guilty" setting limits.
O — OBJECTIVE (mental status / observations)
Alert, oriented x3. Affect brighter, congruent; speech normal rate/volume. Engaged and reflective. No psychomotor agitation. Denies SI/HI, no intent or plan. Cognition intact.
A — ASSESSMENT (progress toward goals; risk)
Generalized anxiety; responding well to CBT. Progress toward Goal 1 (reduce anxiety symptoms) good; Goal 2 (assertive communication) emerging. Risk: low — denies SI/HI, no acute safety concerns.
P — PLAN (interventions, homework, next session, safety)
Continued CBT; cognitive restructuring re: guilt about boundaries; role-played assertive scripts. Homework: thought record 3x; one boundary-setting practice; continue breathing. Next session in 1 week. Safety plan reviewed; client has crisis line (988) and supports.
Risk note: Document any SI/HI assessment and safety plan above. In a crisis,
clients should call or text 988 (Suicide & Crisis Lifeline) or 911. This note
is part of the clinical record and is not a crisis-intervention tool.
Clinician signature: _______________________________ Date: ______________
Dr. Sam Reyes, LCSW
About this template
A SOAP progress note is the working record of a therapy session — for continuity of care, for your clinical/legal record, and for insurance. Each section has a distinct job, and keeping them clean protects both client and clinician. **Subjective** is the client's own report: mood, symptoms (with a rating if you track them), what changed since last time, and what they bring to the session. **Objective** is your observation — a brief mental-status picture (orientation, affect, speech, engagement, psychomotor) and, critically, a clear note on **suicidal/homicidal ideation** (denied, or assessed with intent/plan/means). **Assessment** ties the session to the **treatment goals** — progress, emerging themes, the working diagnosis if applicable, and a **risk level**. **Plan** is forward-looking: the interventions/modality used (e.g., CBT, cognitive restructuring), homework, the next appointment, and any **safety plan**. Two things matter enormously in behavioral health. First, **privacy**: mental-health records are PHI under HIPAA, and "psychotherapy notes" kept separate from the record get heightened protection — store notes securely, and use client initials where appropriate. Second, this is **documentation, not crisis care**: always record SI/HI assessment and a safety plan when relevant, and route acute risk to 988 or 911, not to a form. Write notes timely, factually, and within your scope and license.
When to use it
- Documenting a psychotherapy/counseling session.
- Recording mental status, progress, and risk assessment.
- Supporting insurance billing and continuity of care.
- Noting interventions, homework, and the next session.
What to include
- Clinician, client (name/initials), and session details.
- Subjective (client report, symptom ratings).
- Objective (mental status, SI/HI, engagement).
- Assessment (progress toward goals, diagnosis, risk).
- Plan (interventions, homework, next session, safety) and signature.
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