Free Template
SOAP Note Template for Counseling & Therapy
Mental health professionals including LPCs, LCSWs, psychologists, and marriage and family therapists need clear session documentation for clinical, legal, and insurance purposes. This SOAP note template covers the standard elements required for psychotherapy session notes while maintaining appropriate clinical boundaries.
Blank Counseling & Therapy SOAP Note Template
Copy this template and fill in the bracketed sections with your session details.
SUBJECTIVE: Client reports [presenting concern for this session]. [Mood and affect as described by client]. [Progress on therapeutic goals]. [Significant life events or stressors since last session]. [Sleep, appetite, and functioning]. [Suicidal/homicidal ideation screening: denies/endorses]. OBJECTIVE: Appearance: [grooming, dress]. Behavior: [cooperative, guarded, agitated, engaged]. Speech: [rate, volume, coherence]. Mood: [client-reported]. Affect: [observed — e.g., congruent, flat, labile]. Thought process: [linear, tangential, circumstantial]. Thought content: [no SI/HI, delusions, obsessions]. Cognition: [alert, oriented, memory intact]. Insight/Judgment: [good/fair/poor]. Interventions used: [CBT, DBT skills, EMDR, motivational interviewing, etc.]. ASSESSMENT: [Progress toward treatment plan goals]. [Clinical formulation — connecting symptoms to diagnosis]. [Risk assessment if applicable]. [Therapeutic alliance and engagement]. PLAN: [Focus for next session]. [Homework or between-session assignments]. [Medication coordination if applicable]. [Safety plan updates if needed]. [Next appointment].
Filled Example — Counseling & Therapy
Here's what a completed SOAP note looks like for a counseling & therapy session.
SUBJECTIVE:
Client presents for scheduled weekly individual therapy session. Reports increased anxiety over the past week related to an upcoming performance review at work. Describes worry as "constant" with difficulty concentrating on tasks. Reports sleep has decreased to approximately 5 hours per night (baseline 7 hours) due to racing thoughts at bedtime. Appetite is slightly decreased. Client practiced the progressive muscle relaxation technique discussed last session — used it 3 times this week and found it "somewhat helpful" but reports difficulty using it during acute anxiety at work. Client denies suicidal ideation, homicidal ideation, and self-harm urges.
OBJECTIVE:
Appearance: appropriately dressed, adequately groomed. Behavior: cooperative, seated with crossed arms and fidgeting with hands. Leg bouncing noted. Speech: normal rate and volume, coherent and goal-directed. Mood: "anxious and frustrated." Affect: anxious, congruent with reported mood, full range. Thought process: linear and organized. Thought content: preoccupied with work performance evaluation, no suicidal or homicidal ideation, no delusions or hallucinations. Cognition: alert and oriented, memory intact, concentration slightly impaired (lost track of topic twice). Insight: good — client recognizes anxiety pattern and connects it to fear of negative evaluation. Judgment: good. Interventions: CBT — cognitive restructuring of automatic thoughts related to work performance ("If I get a bad review, I'll be fired and everything will fall apart"). Identified cognitive distortions: catastrophizing, fortune-telling. Collaboratively developed balanced alternative thoughts. Introduced worry time technique (scheduled 15-minute worry period). Reviewed and refined PMR technique with guided practice in session.
ASSESSMENT:
Client meets criteria for Generalized Anxiety Disorder (F41.1). Current symptom exacerbation is situationally triggered by anticipated performance evaluation, consistent with client's core belief pattern around adequacy and fear of negative evaluation (identified in treatment plan). Client is making progress on Goal 1 (reduce anxiety symptoms) — demonstrated willingness to use coping skills between sessions and shows good insight into cognitive patterns. Cognitive restructuring was effective in session — client was able to generate balanced thoughts independently with minimal prompting, representing improvement from early sessions. Sleep disruption warrants monitoring. Risk: low — no SI/HI, protective factors include stable employment, supportive partner, and engagement in treatment.
PLAN:
Continue weekly individual therapy, CBT-focused. Next session focus: deeper work on core belief "I'm not good enough" using downward arrow technique. Between-session assignments: (1) Continue PMR daily at bedtime for sleep. (2) Practice worry time technique — limit worry to designated 15-minute period, 5-7 PM. (3) Thought record: capture 2-3 anxious automatic thoughts this week and identify the cognitive distortion. Coordinate with psychiatrist Dr. [name] if sleep does not improve within 2 weeks — may benefit from short-term sleep medication. Update safety plan: not indicated at this time. Next appointment: [date], 2:00 PM.Documentation Tips for Counseling & Therapy
- Always document SI/HI screening — even when negative, note 'denies SI/HI'
- Separate the client's reported mood (Subjective) from your observed affect (Objective)
- Document specific interventions used with enough detail to show skilled treatment
- Include between-session assignments to demonstrate continuity of care
- Your Assessment should connect observations to the treatment plan and diagnosis
- Maintain appropriate boundaries — document clinically relevant information only
Skip the Template — Generate Notes with AI
Type a quick session summary and Wellistic generates a complete counseling & therapy SOAP note in seconds.
Start Generating Notes in 30 Seconds
Join thousands of wellness practitioners saving hours on documentation every week.