SOAP Note Examples for Mental Health

SOAP notes, a crucial tool for mental health professionals, are used to document their patients’ progress and their interactions during therapy sessions.

In this article, we'll explain how to write a SOAP note for mental health, and provide sample SOAP notes for mental health professionals, including examples for counseling.

The acronym, SOAP, stands for Subjective, Objective, Assessment, and Plan.

The SOAP note format ensures that relevant patient information is captured logically and consistently.

Your note-taking ability probably wasn’t tested during your education in behavioral health.

That’s why we’ve provided basic SOAP note examples for mental health professionals below, with explanations of each section.

What Are SOAP Notes?

There are several kinds of therapy notes, and SOAP notes fall under the progress note category. A subset of clinical notes, these provide details about client progress, such as diagnosis & assessment, symptoms, treatment and progress toward treatment goals. They are included as part of your patient’s medical records and are meant to be shared with your patient’s other healthcare providers.

Progress notes, such as SOAP notes, follow a standard format. Mental health software, like Vagaro’s, offers an intuitive SOAP note feature that breaks this format down simply. There are actually three types of SOAP notes you can add with Vagaro, which this support article explains how to use.

For simplicity’s sake, the following is a breakdown of a common SOAP note, with the kind of information to include, and tone of voice to use, in each section.*:

Subjective

The subjective section of a SOAP note should contain your patient’s subjective complaints and history, i.e., their self-reported symptoms, feelings, and experiences. This section covers things talked about in your session and may include direct quotes from your patient.

The goal of subjective information is to uncover your patient’s chief complaint (CC).

There may be more than one CC present, and your patient may not report on the primary one straight away. Ask as many relevant questions as possible.

In this section, you should uncover:

• Your client’s description of their current emotional state
• Any physical symptoms your client may be experiencing
• Recent life events that may be affecting your client’s mental health
• Your client’s sleep patterns, appetite, energy level & any other relevant information
• Relevant medical history, such as a history of present illness (HPI) and medications your patient may be taking

Remember to include only relevant information. Use only quotes from your patient or important people in their lives connected to their mood, motivation and awareness level. Always make sure these quotes are set apart with quotation marks.

Example for Therapist

Patient, Alex M., reports feelings of helplessness and depression. Alex says, “I just can’t control my thoughts and haven’t been sleeping well.” He reports becoming irritable when in public, saying, “I don’t understand what’s setting me off.” We discussed his sleeping habits, activity level, recent life events and current stressors that may be impacting his mood and sleep.

In this example, the provider documents the client’s self-reported symptoms and provides some context around the client’s current life situation. This information will be helpful in the assessment and planning stages of the SOAP note.

Objective

The objective section of a SOAP note is where you’ll document any pertinent observable and measurable data concerning your patient. Physicians use this field to record vital signs, physical exam findings, or diagnostic test results.

As a mental health professional, you may include such observations as your patient’s appearance, behavior, speech, mood, body posture and affect when discussing certain subjects during your session.

The most important phrase to remember here is objective observations. Avoid assumptions, personal opinions, negative language or general statements that aren’t supported by observable evidence.

Example for Therapist

Alex is cooperative, though he wore a downcast expression during the session and was prone to long pauses when answering questions.

The provider had to repeat several questions, suggesting Alex’s condition is affecting his focus. He would wring his hands and deflect whenever the subject of his military service came up.

In this example, the provider documents their patient’s observable behavior and speech patterns, which can provide insight into the patient’s mental status.

Assessment

The assessment field of your SOAP note is where the first two fields come together. Here, you’ll analyze the subjective and objective data to formulate a diagnosis or clinical impression.

The assessment section may include a summary of your patient’s symptoms, any relevant history, and your clinical impression related to factors such as mood, orientation, risk of harm and assessment of progress towards goals.

Example for Therapist

Based on Alex’s self-report and session observations, the provider notes symptoms of anxiety and major depressive disorder, with signs of PTSD.

Lack of sleep worsens negative mood spirals and racing thoughts. While not yet severe, these symptoms cause distress and impairment. Without intervention, they are likely to worsen.

In this example, the provider analyzes the subjective and objective data available to them to formulate a clinical impression of their patient’s mental health.

Plan

In the plan section of your SOAP note, you’ll outline the next steps in your patient’s treatment. This field should include any interventions or treatments that will be implemented, as well as any referrals or follow-up appointments that are necessary.

You may cover the anticipated frequency & duration of therapy, short & long-term goals and different exercises you’ve asked your client to do between sessions.

Example for Therapist

The provider will continue psychotherapy with Alex on Thursdays at 4 p.m. Alex agreed to attend a local veterans’ group therapy meeting to see if this helps, and report back at our next session. Mutually decided that, in the next week, Alex will contact someone, either a friend from before his time in the military, or someone with whom he served and is close to, to help feelings of isolation. Alex will begin a CrossFit training program, for enjoyment as well as an outlet for depression and negative thoughts. The provider will continue to build trust with Alex, and slowly broach his combat experiences, family history and other sources of stress. Alex was reluctant to begin taking medication. The provider will continue to monitor the severity of his symptoms and will discuss medication again if they worsen. In this example, the provider outlines realistic and measurable goals that they and their patient have agreed upon. Included are physical, social and medical attributes that will contribute to the patient’s therapeutic goals.

You might be wondering if SOAP notes are essentially the same for all mental health professionals (psychotherapist, counselor, etc.). Well, not quite.

While the basic SOAP structure stays the same, the details and depth vary by modality.

Below, we explore differences in SOAP notes used by psychotherapists and counselors.

SOAP Notes Example for Psychotherapist

Psychotherapists tend to dive deeper into the client's psyche, exploring unconscious processes, personality dynamics, and past experiences.

Their SOAP notes, therefore, might reflect a more in-depth analysis of these factors, and focus on long-term goals related to personality change or resolving deep-seated issues.

Here’s an abbreviated example of a psychotherapist’s SOAP notes:

Subjective: Client, Alex, reported a longstanding pattern of anxiety, which has intensified recently due to work pressures. Described feeling overwhelmed, worthless, and fearing failure.

Objective: Alex appeared withdrawn, had difficulty maintaining eye contact, and exhibited low energy. Vital signs within normal limits.

Assessment: Alex presents with generalized anxiety disorder with potential underlying depressive symptoms. Defense mechanisms of avoidance and intellectualization noted.

Plan: Continue exploring Alex’s early childhood experiences related to anxiety. Introduce cognitive-behavioral techniques to challenge negative thought patterns. Consider referral for medication evaluation. Schedule follow-up in two weeks.

SOAP Notes Example for Counseling

Counselors might focus on short-term goals related to specific problems. Their SOAP notes may reflect practical problem-solving, coping skills, and improving overall well-being.

Here’s an abbreviated example of a counselor’s SOAP notes:

Subjective: Client, Alex, reported increased anxiety levels over the past week, specifically related to job performance. Described feeling overwhelmed, restless, and difficulty concentrating.

Objective: Alex appeared tense, exhibited fidgeting, and had a rapid speech pattern. Vital signs within normal limits.

Assessment: Alex is experiencing moderate anxiety related to job-related stressors. Coping mechanisms, such as relaxation techniques, seem insufficient now.

Plan: Continue exploring anxiety management techniques with Alex. Introduce progressive muscle relaxation. Develop a stress management plan. Schedule follow-up in one week.

The counselor's note focuses on immediate anxiety management strategies, while the psychotherapist's note explores deeper underlying issues and long-term treatment goals.

It is common for therapists to incorporate elements of other approaches. It is important to remember, also, that the specific focus of the session, the theoretical orientation of the therapist, and the client's presenting problem will significantly influence the content of the SOAP note.

Let’s look at examples for two of the most common issues, clinical depression, and anxiety, from the perspectives of both psychotherapists and counselors.

SOAP Notes Example for Depression

Depression (Psychotherapist)

Subjective: Client, Alex, reported persistent feelings of sadness, emptiness, and hopelessness for several months. Decreased interest in previously enjoyed activities, social withdrawal, and changes in appetite and sleep patterns. Reports difficulty concentrating, feelings of worthlessness, and recurrent thoughts of death without specific plans.

Objective: Alex presents with a flat affect, decreased eye contact, and slowed speech. Appears disheveled and withdrawn.

Assessment: Alex exhibits symptoms consistent with Major Depressive Disorder. Depressive symptoms are significantly impairing occupational and social functioning. Possible underlying unresolved grief and anger based on client's history.

Plan: Continue exploring Alex’s early life experiences and attachment patterns. Introduce psychodynamic therapy to uncover unconscious conflicts contributing to depression. Implement interpersonal therapy to address relationship difficulties. Consider medication consultation. Schedule follow-up in two weeks.

Depression (Counselor)

Subjective: Client, Alex, reported feeling sad and down for the past month. Decreased interest in hobbies, difficulty sleeping, and changes in appetite. Feeling overwhelmed and unable to cope with daily tasks.

Objective: Alex appeared downcast with decreased energy.

Assessment: Alex is experiencing symptoms of depression related to recent life stressors. Coping skills are overwhelmed.

Plan: Develop a daily routine with Alex to increase structure and activity levels. Teach relaxation techniques to manage stress. Introduce problem-solving skills to address current challenges. Explore support systems and encourage social connection. Schedule follow-up in one week.

SOAP Notes Example for Anxiety

Anxiety (Psychotherapist)

Subjective: Client, Alex, reported excessive worry and anxiety for the past six months. Difficulty concentrating, irritability, muscle tension, and sleep disturbances. Physical symptoms include palpitations, sweating, and shortness of breath. Avoids social situations due to fear of judgment.

Objective: Alex appears restless and agitated. Increased muscle tension and rapid speech. Difficulty maintaining eye contact.

Assessment: Alex presents with symptoms consistent with Generalized Anxiety Disorder. Anxiety is significantly impairing occupational and social functioning. Possible underlying attachment issues based on client's history.

Plan: Explore Alex’s early childhood experiences related to safety and security. Introduce psychodynamic therapy to address underlying anxieties. Implement exposure therapy to challenge avoidance behaviors. Consider medication consultation. Schedule follow-up in two weeks.

Anxiety (Counselor)

Subjective: Client, Alex, reported feeling nervous and worried most of the time. Difficulty concentrating, restlessness, and irritability. Physical symptoms include muscle tension and difficulty sleeping.

Objective: Alex appears tense and fidgety.

Assessment: Alex is experiencing symptoms of anxiety related to multiple stressors. Coping skills are inadequate.

Plan: Teach Alex relaxation techniques to manage physical symptoms. Introduce cognitive-behavioral techniques to challenge anxious thoughts. Develop a stress management plan. Encourage regular exercise and healthy lifestyle habits. Schedule follow-up in one week.

Final SOAP Note Checklist

There are certain important guidelines that you, as a mental health professional, must remember when writing SOAP notes:

• SOAP notes should be concise, objective & relevant to your patient’s treatment plan.
• Ensure accuracy of dates, times, names & tenses. Avoid obscure abbreviations or colloquialisms.
• Always attribute patient statements with quotation marks and qualify subjective statements with evidence.
• Don’t erase or remove errors. Rather, use a strikethrough, identify that spot as an “error,” and correct it.
• Avoid moral judgements when representing your patient and use terminology that is accepted in the mental health field.
• Write your SOAP notes promptly after the session to ensure accuracy and completeness.

Video Telehealth SOAP Notes

Progress notes are also required of telehealth sessions. Below are things to include in your SOAP notes if you are conducting therapy via telehealth:

• Session begin & end time
• A statement indicating that the session was provided via telehealth
• Your location, i.e, home vs. office (ensure that your location reflects the office address that your insurance company has on file).
• Names of all session participants (in the case of families, couples, etc..)
• Date of the next session
• The interventions
• Mental status of patient

*Disclaimer: These examples are intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

——– Proper documentation demonstrates your clinical competence. It also shows how you address patient needs. Though it may seem tedious, it is essential for effective treatment.

Vagaro’s HIPAA-compliant software simplifies mental health SOAP notes and patient documentation. All notes are automatically stored to a patient’s profile for easy future access. Switching to paperless EMR patient notes and forms helps streamline your practice. Vagaro makes private practice management more efficient, allowing you to focus on patients. Taking better care starts with Vagaro. Sign up for your FREE 30-day trial and see for yourself!