SOAP Note Example
Group Therapy SOAP Note Example
Below is a complete SOAP note example for an individual participant in a grief and loss support group. This example demonstrates how to document individual clinical progress within a group therapy context, including group dynamics, peer interactions, participation level, session structure, and individual treatment goals.
Complete Group Therapy Note
SUBJECTIVE:
Client is a 56-year-old female attending session 6 of 12 in a closed grief and loss support group (weekly, 90 minutes). Group format: 8 members, co-facilitated by two licensed clinical social workers. Client's presenting issue: death of her husband of 28 years from pancreatic cancer, 5 months ago. Client reported at check-in that this past week was "harder than usual" because she encountered their wedding anniversary — the first since his passing. States she spent the day alone at home and "couldn't stop crying," estimating she cried intermittently for most of the afternoon. Reports she considered reaching out to her sister but ultimately did not, stating "I didn't want to burden anyone — they've already done so much." Describes a return of difficulty sleeping — waking at 3-4 AM and unable to fall back asleep, lying in bed with memories "playing on a loop." Reports appetite has been diminished over the past week, skipping lunch most days and eating small dinners. Endorses fatigue, difficulty concentrating at work (she is a school librarian), and a sense of "going through the motions" at her job. States she has been avoiding social gatherings and declined an invitation to a coworker's retirement party because "being around people who are happy feels like too much right now." Reports she has continued her individual therapy sessions (biweekly with Dr. Rachel Torres, LCSW) and found last week's session helpful for processing anticipatory grief around the anniversary. Denies suicidal ideation — when asked directly, stated "I don't want to die — I just miss him." Denies self-harm, substance use changes, and homicidal ideation. Reports she has been taking sertraline 100 mg daily as prescribed by her psychiatrist, Dr. Eric Patel, with no side effects.
OBJECTIVE:
Group session structure: check-in (20 minutes) — each member shared a brief update on their week and rated their grief intensity on a 0-10 scale; psychoeducational component (15 minutes) — facilitator-led discussion on the concept of grief triggers and anniversary reactions, with a handout on anticipatory coping for significant dates; experiential activity (25 minutes) — guided letter-writing exercise in which members wrote a letter to their deceased loved one about something they wished they could share with them; group processing (25 minutes) — open discussion of the letter-writing experience and emerging themes; closing (5 minutes) — each member identified one coping resource they would use this week. Client's participation and behavior: client's grief intensity self-rating at check-in was 8/10, compared to 5/10 at session 5 and her baseline of 7/10 at session 1. During check-in, she spoke for approximately 3 minutes — longer than her typical contribution of 1-2 minutes in prior sessions — and made sustained eye contact with the group while sharing about the anniversary, though her voice was trembling and she teared up. Two group members verbally offered support; one member (who lost her spouse 14 months ago) shared her own experience of the first anniversary, normalizing the intensity of the client's reaction. Client nodded and whispered "thank you — that helps to know." During the psychoeducational segment, client listened attentively, took notes on the handout, and asked one question: "Does it ever stop being this intense on those dates?" — indicating active engagement and future-oriented thinking. During the letter-writing activity, client wrote for the full allotted time. She became visibly emotional — tears streaming, shoulders shaking — but did not request to stop and declined the facilitator's offer to step out, stating "I need to do this." Her letter was addressed to her husband and described wanting to tell him about their granddaughter's first steps. During group processing, she volunteered to read a portion of her letter aloud — this was the first time she has shared written work with the group. Her reading was met with supportive silence and several members expressed being moved by her words. After sharing, her affect shifted — she appeared relieved and stated "I didn't think I could do that." She made a spontaneous supportive comment to another member who was struggling to articulate her feelings, saying "Take your time — we're all here." At closing, client identified journaling before bed as her coping resource for the week. Mental status observations: appearance — casually dressed, adequate hygiene, dark circles under eyes suggesting fatigue. Affect — tearful and constricted during the first half of the session, gradually broadening to include moments of warmth and gentle humor during processing; congruent with content throughout. Speech — soft-spoken with occasional breaks in voice, normal rate. Thought process — linear, coherent, reflective. Risk: no suicidal ideation, no self-harm, no homicidal ideation; risk level low.
ASSESSMENT:
Client is 5 months into acute grief following the death of her spouse and is experiencing an expected grief exacerbation related to the first wedding anniversary — a well-documented grief trigger. The increase in grief intensity from 5/10 to 8/10 this week is clinically consistent with anniversary reactions and does not represent a deterioration in her overall grief trajectory, which has shown gradual improvement from 7/10 at session 1 to a general range of 4-6 between major trigger dates. Sleep disruption, appetite decrease, social avoidance, and concentration difficulty are proportionate to the grief trigger and do not currently meet criteria for a major depressive episode distinct from the bereavement process — these symptoms will be monitored over the next 2-3 sessions to ensure they return to her recent baseline as the anniversary period passes. Notably, the client demonstrated significant therapeutic progress in today's session: she shared more extensively during check-in than in any prior session, persisted through a difficult emotional exercise (letter writing) despite visible distress, and voluntarily read her letter to the group for the first time — all representing increased vulnerability and trust within the group, which are key therapeutic factors in grief group work. Her spontaneous supportive comment to another group member indicates she is beginning to shift from a solely receptive role to a giving role within the group, which research associates with improved grief outcomes. The client's statement "I didn't think I could do that" reflects growing self-efficacy around emotional expression. Her reluctance to reach out to her sister during the anniversary ("I didn't want to burden anyone") is a cognitive pattern worth addressing — the belief that seeking support is burdensome may be contributing to her social isolation and should be explored in both group and individual therapy.
PLAN:
Continue weekly grief and loss group — session 7 next week. Individual goals for the next session: monitor whether sleep, appetite, and social withdrawal return to her recent baseline now that the anniversary date has passed; if these symptoms persist at elevated levels beyond 2 weeks, coordinate with individual therapist Dr. Torres and psychiatrist Dr. Patel to evaluate for possible medication adjustment or more intensive individual work. Facilitator to gently explore the "not wanting to be a burden" theme in the next group session if it arises naturally in discussion, or raise it during the check-in by asking how members navigate asking for support on difficult days. Homework for client: continue journaling before bed as she identified during closing — specifically, try writing 3 things she is grateful for alongside processing grief content to introduce a balanced emotional practice; attempt to reach out to one support person (sister, friend, or individual therapist) the next time she is having a difficult day rather than managing alone. Coordination of care: facilitator will send a brief progress update to individual therapist Dr. Torres (with client's signed release on file) summarizing the anniversary reaction and the client's increased group participation. Risk assessment: current risk level remains low. Continue to assess at each group session. If client endorses suicidal ideation, facilitate immediate individual safety assessment and crisis intervention protocol. Next formal individual treatment plan review with client at session 9 (midpoint reassessment) to evaluate progress toward treatment goals: reducing grief intensity to a sustained 4/10 or below, re-engaging in at least one social activity per week outside of therapy, and restoring sleep to 6 or more hours per night consistently.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
Group therapy SOAP notes document individual clients, not the group as a whole — each member receives their own note. The subjective section captures the client's self-report at check-in and throughout the session, including their current grief intensity rating, how they have been functioning since the last session, specific triggers or events that occurred during the week, and their experience of coping or not coping. Document what the client said in their own words when possible, including quotes that reveal cognitive patterns (the "burden" belief). Include concurrent treatment information (individual therapy, medication management) because group therapy typically operates within a broader treatment ecosystem. Risk screening must be documented for each individual group member at every session, even when the member is consistently low-risk.
Objective
The objective section for group therapy notes must document both the session structure and the individual client's participation within that structure. Begin with the session format — describe the check-in, psychoeducational component, experiential activity, processing discussion, and closing so that any clinician reviewing the note understands what occurred. Then document the specific client's behavior: how much they participated, their affective presentation, notable interactions with peers (both receiving and offering support), and their engagement with exercises and activities. Compare participation to prior sessions to show trajectory (spoke for 3 minutes versus the typical 1-2 minutes; first time sharing written work). Group dynamics observations — such as peer support received and offered — are unique to group therapy documentation and demonstrate the therapeutic factors at work. Include brief mental status observations relevant to the session.
Assessment
The group therapy assessment interprets the client's current presentation within the context of their grief trajectory and the group therapeutic process. Distinguish between expected grief fluctuations (anniversary reactions) and potential clinical deterioration by referencing the client's broader symptom pattern over multiple sessions. Identify the therapeutic gains observed in the session — increased vulnerability, voluntary sharing, peer support behaviors — and connect them to the therapeutic factors that make group therapy uniquely effective (universality, altruism, interpersonal learning). Highlight cognitive patterns that emerged (the burden belief) as targets for future work. This section should make it clear why group therapy specifically, rather than individual therapy alone, is clinically beneficial for this client at this stage of their grief process.
Plan
The group therapy plan addresses the individual client's goals within the group context and coordinates with their broader treatment team. Include specific facilitator intentions for the next session (exploring a particular theme), individual homework that extends the session's therapeutic work, and criteria for escalation if symptoms do not improve on a defined timeline. Coordination of care with the individual therapist and prescribing provider is essential and should be documented with specifics (what information will be shared and with what consent). Include the timeline for formal treatment plan reassessment — in group therapy this often aligns with the group midpoint or a predetermined number of sessions. State measurable treatment goals with target values so that progress can be evaluated objectively at the reassessment point.
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