COUNSELING 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]