Session Note (SOAP)

A brief, structured record of today's session. The SOAP format helps us track progress, communicate with treatment partners, and document our shared work clearly and respectfully.

Header

Client name:

Session number:

Session date:

Modality:

[ ] In-person [ ] Video [ ] Phone

Session length (minutes):

Therapist:

Subjective — Client's Report

What the client shared today — in their words:

Mood scale (1 = very low, 10 = very good):

Sleep over the past week (typical hours / quality):

Significant events since last session:

Objective — Therapist Observations

Appearance:

[ ] Well-groomed [ ] Casual / typical [ ] Disheveled / changed from baseline

Engagement:

[ ] Highly engaged [ ] Engaged [ ] Reserved [ ] Withdrawn

Affect:

[ ] Full range, congruent [ ] Restricted [ ] Flat / blunted [ ] Labile

Speech:

[ ] Normal rate, rhythm, prosody [ ] Pressured / rapid [ ] Slowed / soft

Engagement quality (e.g. "open and reflective"):

Notable shifts during session:

Assessment — Progress

Goal progress (1 = no movement, 5 = strong progress):

Risk re-assessment:

[ ] Low — no current concerns [ ] Monitor — watch for changes [ ] Elevated — increased attention warranted [ ] Immediate concern — safety plan activated

Notes if elevated or immediate (steps taken, supports contacted, plan):

Plan

Focus for next session:

Homework or between-session practice given:

Resources or referrals shared:

Next session date:

Supervision / Consultation

[ ] Discussed in supervision or peer consultation

Supervisor / consultant name:

Sign-off

Therapist signature:

Date signed:

[ ] Note completed and reviewed

Thoughtful documentation supports continuity of care. Keep this note concise but specific — your future self and any treatment partners will thank you.