A counseling SOAP note records a session in four parts: what the client reports, what you observe and measure, your clinical impression, and the plan. Copy the free template, see a school-based and an adult outpatient example, and check what goes in each section.
Blank counseling SOAP note template
FreeCOUNSELING SOAP NOTE Client: [Name or ID] Date of session: [Date] Session: [Number, length in minutes, in person or telehealth] Clinician: [Name, credentials] SUBJECTIVE Client report: [How the client describes the time since the last session, in their words where useful] Symptoms: [Mood, anxiety, sleep, appetite, energy, concentration, as the client describes them] Stressors and events: [What has happened since the last session] Functioning: [Home, work or school, relationships, self-care] Coping and homework: [Skills the client tried, and how they went] Substance use: [Alcohol, cannabis, or other drugs since the last session, or none reported] OBJECTIVE Appearance and behavior: [Grooming, eye contact, motor activity, engagement] Speech: [Rate, volume, tone] Mood and affect: [Mood in the client's words; affect as observed: range, intensity, congruence] Thought process: [Logical, tangential, slowed, or racing] Thought content and perception: [Main themes; any obsessions, delusions, or hallucinations] Cognition, insight, and judgment: [Orientation and attention; insight and judgment as good, fair, or limited] Measures: [PHQ-9, GAD-7, or other scores today, with the previous score and its date] ASSESSMENT Clinical impression: [Diagnosis or working impression, and how today's findings fit] Progress: [Toward each treatment plan goal: better, unchanged, or worse, with evidence] Risk: [Suicidal ideation, self-harm, harm to others: what was asked, the answers, and your judgment] Helping and hindering: [What supports or blocks progress] PLAN Interventions this session: [Techniques used today, and the goal each targets] Interventions planned: [What you will work on next, and why] Homework: [What the client will practice before the next session] Coordination: [Contact with family, school, physicians, or other providers, with consent] Next session: [Date, frequency, and format] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient counseling, session 3, by video
41-year-old man. Work has been “relentless” since his team was cut in half 2 months ago; working about 55 hours a week. Low mood most days, less interest in cycling, waking at 4 a.m. thinking about work. Appetite unchanged. Now drinks 3 beers on most evenings to unwind, up from weekends only. Used the scheduled worry time from last session on 3 days; it helped him get back to sleep twice.
Video session; client alone in a private room at home, location confirmed. Casually dressed, looks tired. Good eye contact. Speech normal rate, low volume. Mood “flat”; affect constricted, brighter when talking about his children. Thought process logical; content focused on workload and fear of letting his team down. Alert and oriented; insight good. PHQ-9 11, down from 13 at intake. GAD-7 10. AUDIT-C 5.
Adjustment disorder with mixed anxiety and depressed mood, linked to the change at work; does not meet criteria for a major depressive episode at this point. Slightly better since intake. More drinking is a new concern and may be worsening sleep and mood. Risk: denies suicidal thoughts, plans, or intent, and self-harm; no thoughts of harming others. Protective factors: his children, his partner, and his engagement in counseling.
Today: behavioral activation, scheduling two bike rides; problem-solving on workload, drafting points to raise with his manager; information on alcohol, sleep, and mood. Next: continue activation and start cognitive work on “I’m letting everyone down.” Homework: two rides, nightly worry time, and alcohol-free evenings on 3 weeknights with a drink log. Coordination: suggested a visit to his primary care clinician about sleep and mood; he will book it. Next session in 1 week by video. Contact the clinic if mood worsens; call 911 or go to the nearest emergency department for thoughts of self-harm.
What the client tells you about the time since the last session, in their words where it matters.
Avoid: Interpreting here. “Client is avoidant” is your assessment; “ate lunch in the library 4 of 5 days” is the client’s report.
What you observe in the session and the scores you measure. In counseling, that means a brief mental status exam plus standardized measures.
Avoid: Moving the client’s report into Objective. “Reports feeling anxious” is subjective; “fidgeting, fast speech, tense posture” is objective.
Your clinical impression and the client’s progress, with the reasoning that connects Subjective and Objective to it.
Avoid: Scores with no meaning attached. A PHQ-9 that fell from 13 to 11 is a change worth interpreting.
What you did today and what happens next, tied to the treatment plan.
Avoid: “Continue current treatment” with no detail. Name the next step and the goal it serves.
A full “within normal limits” exam pasted into each note hides real change. Record the domains you observed today, and what was different.
If you give a PHQ-9 or GAD-7, put the score in Objective and say what it shows in Assessment. Scores no one interprets look like box-ticking.
Document the screen every session, negatives included: what you asked and what the client said. A missing risk line reads as a missing question.
When you update a parent, teacher, or employer, share the minimum needed, with the client’s agreement, and note what you shared and with whom.
If you assign practice, ask about it at the next session and record what happened. Homework that is never reviewed soon stops getting done.
Vero Scribe writes the counseling SOAP note in your template from the session conversation, with the client’s consent, or from your dictation. You review and edit it, then copy it into your record, or export, print, or email it.
What you observe and measure: appearance, behavior, speech, mood and affect, thought process and content, cognition, insight, and judgment, plus scores from measures such as the PHQ-9 or GAD-7. What the client tells you belongs in Subjective.
Either works if it is complete and used consistently. SOAP keeps the client’s report apart from your observations, which helps when you track symptoms and scores; DAP combines them under Data and is quicker for routine sessions.
Both ask about the past 2 weeks, so many clinicians repeat them every 2 weeks, or every session early in treatment, then less often once the client is stable. Record each score with its date so change is easy to see.
Yes. Add who consented to counseling, who else attended, and what you agreed to share with parents or guardians. The teen social anxiety example above is a school-based session.
Yes. Copy it, or download it as a Word or text file. No account needed.
The four-part note for most visits, with acute, musculoskeletal, and telehealth examples.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
The first session: consent, history, risk, mental status, screening scores, and recommendations.
Biological, psychological, social, and cultural factors, brought together in one formulation.
Problems, goals, measurable objectives, interventions, and review dates, agreed with the client.
DAP, SOAP, and BIRP notes, drafted from your sessions.
What to record in each MSE domain.
A step-by-step guide, with a checklist and common mistakes.
Notes, documents, and follow-up in one workspace.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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