SOAP Notes Template

Patient Name:
Date of Service:
Session Number:
Therapist:

Subjective (S):
The subjective section is where you record the client's statements and expressions of their personal experiences. This is the client's narrative or report of their problems or progress.

- Client's subjective description of their mood, feelings, and perceptions.
- Quotes or paraphrased statements from the client.
- Relevant personal stories or events shared by the client.

Objective (O):
The objective portion includes observable facts and the counselor’s observations during the session.

- Nonverbal behaviors observed (e.g., body language, tone of voice).
- Appearance and motor activity.
- Any assessments or scales used and their results.
- Direct observations rather than interpretations.

Assessment (A):
In the assessment, the counselor provides their professional judgment regarding the client's situation, which may include diagnosis, progress, and any changes in condition.

- Diagnosis or diagnostic impressions.
- Progress towards goals.
- Changes in symptoms or behaviors.
- Risk assessment.

Plan (P):
This is the counselor's plan for future sessions and may include homework for the client, any changes to treatment, and other recommendations.

- Next steps in treatment.
- Any homework or tasks assigned to the client.
- Changes to the treatment plan.
- When the next session will occur.