Initial intake and mental health screening, treatment plan and therapy agreement, session notes (SOAP), progress reviews, and termination summaries for psychology counseling practices and licensed therapists
Get started with PocperA 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.
Client name:
Session number:
Session date:
Modality:
[ ] In-person [ ] Video [ ] Phone
Session length (minutes):
Therapist:
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:
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[ ] Highly engaged [ ] Engaged [ ] Reserved [ ] Withdrawn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:
Goal progress (1 = no movement, 5 = strong progress):
Goal | Progress (1-5) | Notes |
|---|---|---|
Goal 1 | ||
Goal 2 | ||
Goal 3 |
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):
Focus for next session:
Homework or between-session practice given:
Resources or referrals shared:
Next session date:
[ ] Discussed in supervision or peer consultation
Supervisor / consultant name:
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.
The Session Note (SOAP) template is a ready-to-use form from Pocper's Psychology Counseling Practice pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.