How to write SOAP Notes for Mental Health Counseling
GUIDE
It's 7 PM. You've just finished your last session, and you're staring at a pile of progress notes that need to be written. Sound familiar? After 15 years as a mental health professional, I've learned that thoughtful documentation isn't just about meeting requirements - it's about capturing the subtle shifts in your clients' journey and protecting your practice.
Why Therapy Notes Matter in Mental Health
Most of us weren't as formally trained on SOAP therapy notes in graduate school as we'd have liked. Yet, they're crucial for tracking therapeutic progress, ensuring continuity of care, and yes - getting reimbursed by insurance companies. The key is understanding how to capture both the art and science of therapy in your documentation.
SOAP Note format for Counseling
The most classic/ widely used template used in mental health counseling is the SOAP note format. This comprehensive guide will explore SOAP notes in detail, providing examples and templates, along with nuances around how to handle difficult situations in your documentation. Writing SOAP notes can even be enjoyable with time.
The Art of Writing Each Section
SOAP therapy notes are much like any other type of SOAP note, and have the same 4 sections:
- S (Subjective)
- O (Objective)
- A (Assessment)
- Plan (Plan)
We will look at how to write each of these sections effectively. For a comprehensive guide with SOAP note templates along with other mental health note templates, refer here.
S (Subjective): Capturing the Therapeutic Narrative
The Subjective section is where we capture the client's voice and experience. This isn't just about listing symptoms - it's about documenting the client's journey in their own words while highlighting clinically significant information.
What to Include:
Direct quotes that illustrate insight or challenges
Changes in symptoms and functioning
Progress on therapeutic homework
New stressors or triggers
Client's perception of their progress
Relevant interpersonal dynamics
Example of Poor Documentation: "Client is anxious about work and relationships. Says things are hard."
Example of Effective Documentation: "Client reports increased anxiety about upcoming job transition, stating 'I lie awake rehearsing every possible worst-case scenario.' Describes physiological symptoms (racing heart, shallow breathing) occurring 4-5 times daily, up from 2-3 times reported last session. Notes relationship with partner is 'on thin ice' due to emotional withdrawal. Has completed breathing exercises 3/7 days since last session, reports they are 'somewhat helpful when I actually do them.'"
O (Objective): Clinical Observations
Clinical observations are crucial for establishing medical necessity and tracking progress. Focus on observable behaviors and clinical patterns rather than interpretations.
Key Elements:
Affect and emotional expression
Quality and content of thought process
Level of engagement in session
Behavioral observations
Risk indicators
Mental status elements
Example of Poor Documentation: "Client seemed sad and anxious. Poor eye contact."
Example of Effective Documentation: "Client presents with constricted affect, shifting to tearful when discussing recent job loss. Speech is soft but clear, with notable latency in response to questions about support systems. Maintains minimal eye contact throughout session, body oriented away from therapist. Observed repeated hand-wringing when discussing financial concerns. Thought process is logical and goal-directed, though shows tendency toward catastrophic thinking regarding future employment. No evidence of perceptual disturbances or delusional content."
A (Assessment): Clinical Reasoning and Patterns
The Assessment section demonstrates your clinical thinking and justifies continued treatment. This is where you connect the dots between observations, interventions, and treatment goals.
Essential Components:
Progress toward treatment goals
Effectiveness of interventions
Risk assessment updates
Pattern recognition
Diagnostic impressions
Treatment barriers
Example of Poor Documentation: "Client is making progress. Depression continues. Will keep working on coping skills."
Example of Effective Documentation: "Client demonstrates incremental progress in depression management, evidenced by increased engagement in behavioral activation tasks and improved sleep hygiene (now reporting 6 hours continuous sleep vs. 4 hours at treatment onset). While passive suicidal ideation persists, client shows strengthened protective factors through renewed church involvement and weekly contact with sister. CBT interventions appear most effective when focused on behavioral components; cognitive restructuring remains challenging due to deeply entrenched negative self-schema. Current presentation continues to meet criteria for Major Depressive Disorder, moderate, with treatment resistance suggesting need for potential medication evaluation."
P (Plan): Strategic Next Steps
Your plan should be specific, actionable, and clearly tied to treatment goals. This section justifies continuing care and sets the stage for upcoming interventions.
Key Elements:
Specific interventions for next session
Modifications to treatment approach
Homework assignments
Referrals or consultations needed
Safety planning updates
Frequency and duration of treatment
Example of Poor Documentation: "Continue weekly therapy. Assigned homework."
Example of Effective Documentation: "1. Continue weekly sessions with increased focus on trauma processing using CPT framework 2. Introduce written trauma narrative next session if stability maintains 3. Assign: Complete Impact Statement worksheet; continue daily mood tracking 4. Coordinate with psychiatrist re: sleep difficulties 5. Review and update safety plan given recent increase in triggering content at work 6. Next session scheduled for 1/27/25 at 2pm"
Refer to this guide for list of 18 mental health soap note templates.
Complex Scenarios: SOAP Note Examples
SOAP Note Example 1: Initial Session with Complex Trauma History
S: Client presents seeking therapy following recent activation of childhood trauma symptoms. Reports "feeling like I'm falling apart" after encountering former abuser at family gathering. Describes 2 weeks of disrupted sleep (averaging 3-4 hours/night), intrusive memories, and heightened startle response. States "I thought I was past all this, but it feels like I'm 12 years old again." Reports previous therapy (2015-2017) was "somewhat helpful" but discontinued due to insurance changes.
O: Client presents as hypervigilant, frequently scanning room and startling at outside noises. Affect is constricted with occasional tearfulness when discussing trauma history. Speech is pressured but coherent. Thought process shows some disorganization when approaching trauma content but remains generally logical. No current suicidal/homicidal ideation reported or observed. Demonstrates good insight into need for treatment.
A: Client presents with symptoms consistent with reactivated PTSD related to childhood abuse. Current functioning shows significant impairment in sleep, interpersonal relationships, and emotional regulation. Risk assessment indicates low current risk with strong protective factors (supportive spouse, stable employment, clear future orientation). Client demonstrates good candidacy for trauma-focused treatment given prior therapy experience and current motivation.
P: 1. Begin weekly therapy focusing on stabilization and coping skill development 2. Provide psychoeducation about trauma responses and window of tolerance 3. Introduce grounding techniques and containment strategies 4. Complete formal trauma assessment next session 5. Consider referral for psychiatric evaluation if sleep disturbance persists 6. Schedule next session for following week
SOAP Note Example 2: Crisis Intervention Session
S: Client called crisis line reporting suicidal ideation with plan. States "I can't do this anymore" and discloses stockpiling medication. Recent stressors include job loss (2 weeks ago) and relationship breakup (yesterday). Reports feeling "hopeless" and "like a burden to everyone." Denies current substance use but reports increased alcohol consumption over past two weeks ("maybe 4-5 drinks nightly").
O: Client appears disheveled and actively crying throughout session. Speech is slurred but coherent. Mood severely depressed with congruent affect. Thought process shows prominent hopelessness and worthlessness themes. Acknowledges suicidal intent with specific plan. Minimal engagement with safety planning initially but gradually becomes more cooperative.
A: Client presents with acute suicidal risk requiring immediate intervention. Risk factors include recent losses, active substance use, specific plan, and intent. Protective factors limited but include willingness to engage in safety planning and historical connection to religious community. Current presentation consistent with Major Depressive Disorder, severe, with recent significant decompensation.
P: 1. Completed suicide risk assessment and safety plan 2. Secured commitment to safety for next 24 hours 3. Arranged emergency psychiatric evaluation at County Crisis Center 4. Called client's sister (with permission) to provide transportation 5. Provided crisis hotline numbers and backup resources 6. Schedule follow-up session after psychiatric evaluation
SOAP Note Example 3: Couples Therapy Session
S: Couple presents with escalating conflict around financial management. Partner A (Jane) reports feeling "controlled and infantilized" regarding spending decisions. Partner B (Tom) expresses frustration about "secretive purchases" and lack of consultation on major expenses. Both identify communication breakdown as central concern. Recent argument resulted in Jane staying at sister's house for two nights, first separation in 12-year marriage.
O: Partners demonstrate high emotional reactivity when discussing finances. Jane appears tense, frequently interrupting Tom with defensive responses. Tom shows tendency to shut down and withdraw when criticized. Some ability to regulate with therapist intervention. Both partners able to identify shared goal of improving communication despite current distress.
A: Couple presents with communication difficulties exacerbated by financial stressors. Interaction patterns show pursue-withdraw dynamic typical of attachment injuries. Both partners demonstrate insight into their contributions to conflict but struggle with emotional regulation when triggered. Relationship appears to have good prognosis given long history of stability and shared commitment to improvement.
P: 1. Continue weekly couples sessions focusing on communication patterns 2. Introduce emotional regulation strategies for use during financial discussions 3. Assign "speaker-listener" technique practice with low-stakes topics 4. Provide financial communication worksheet for homework 5. Consider referral for financial counseling if needed 6. Next session scheduled for 1/27/25
Using AI to automate SOAP Notes
New AI products have made it possible to completely automate your documentation. Tools like Supanote can learn to write exactly like you, and write notes automatically at the end of each session
How AI Therapy Note Tools Work
Most of these products typically work like this: Supanote and similar platforms can:
Listen to therapy sessions in real-time; Alternatively, you can just dictate your recollection after each session
Generate full structured SOAP notes
Maintain clinical accuracy
Ensure compliance standards
Some of the benefits include:
You get a note immediately after the session
You can focus on your client during the session
Improved work-life balance
Consistency of format
Tips for Using AI Note Tools Effectively
Check and ensure the tool is HIPAA compliant. Everybody claims they are, but they should be able to provide you with an audited certificate if asked
Set up your own note style on the product. On Supanote, you can do that here
Use as a tool, not a replacement
Notes by Psychologists vs Social Workers
Mental health documentation varies across disciplines, with social workers, psychologists, and counselors often adopting different approaches. While psychologists traditionally favor SOAP format for their clinical notes, social workers often gravitate toward both SOAP and DAP notes depending on their setting and requirements.
Here's how documentation typically varies:
Psychologists' SOAP notes tend to focus on:
Diagnostic impressions
Cognitive and behavioral patterns
Treatment modality effectiveness
Psychological test results
Treatment plan progress
Social workers' therapy progress notes (whether SOAP or DAP) often emphasize:
Environmental factors
Resource utilization
Systems interventions
Client advocacy efforts
Community support integration
For example, a SOAP note example from a social worker might include more details about the client's interaction with various systems:
S: Client reports difficulties accessing food stamps and describes increased anxiety about feeding their children. States "The system is impossible to navigate."
O: Client presented relevant documentation showing multiple attempted applications. Demonstrated visible frustration when discussing interactions with social services.
A: Client's anxiety appears exacerbated by systems barriers. Current challenges with basic needs are impacting overall mental health functioning.
P: 1. Provide referral to benefits navigator at community center
2. Continue anxiety management techniques
3. Coordinate with food bank for immediate assistance
4. Schedule follow-up after benefits appointment
Whether using SOAP format or DAP notes, the key is ensuring your clinical notes align with both professional standards and agency requirements while effectively documenting client care.
FAQs
Q: How long should a SOAP note be?
A: While there's no strict length requirement, aim for comprehensiveness while remaining concise. Typically, a thorough SOAP note ranges from 250-400 words, though crisis sessions or initial assessments may require more detail.
Q: What about documenting risk?
A: Always document any risk assessment conducted, even if negative for risk. Include specific quotes about suicidal/homicidal ideation, risk factors identified, protective factors present, and actions taken.
Q: How do you handle sensitive information?
A: Document clinically relevant information objectively. Focus on what's necessary for treatment planning and continuity of care. Consider keeping separate psychotherapy notes for sensitive details not required in the medical record.
Q: When should notes be completed?
A: Best practice is to complete notes within 24 hours of the session while details are fresh. Many practices require same-day documentation for crisis sessions or high-risk situations.
Q: How do you document multiple issues in one session?
A: Focus on the primary presenting issue and note others as they relate to the main focus. Use clear organization to show how issues interconnect and impact treatment planning.
Q: Are AI-generated notes insurance compliant?
A: Yes, when using platforms like Supanote that are specifically designed for mental health documentation. Always review and sign notes to ensure they meet your clinical standards and requirements.
Remember: Mental health soap notes tell the story of your client's therapeutic journey while protecting your practice and ensuring continuity of care. Whether written manually or with AI assistance, thoughtful clinical documentation supports all other mental health professionals that interact with the patient after you to improve the quality of their care.