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.
[ ] In-person [ ] Video [ ] Phone
Session length (minutes):
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
[ ] Well-groomed [ ] Casual / typical [ ] Disheveled / changed from baseline
[ ] Highly engaged [ ] Engaged [ ] Reserved [ ] Withdrawn
[ ] Full range, congruent [ ] Restricted [ ] Flat / blunted [ ] Labile
[ ] 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):
[ ] 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):
Homework or between-session practice given:
Resources or referrals shared:
Supervision / Consultation
[ ] Discussed in supervision or peer consultation
Supervisor / consultant name:
Tap to sign
Draw your signature in the popup
[ ] 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.