SOAP Notes for Therapy: Template, Examples, and a Simple Writing Guide
SOAP notes give a therapy session a reliable shape. Instead of staring at a blank page, you answer four smaller questions: What did the client report? What did you observe? What does it mean? What happens next?
SOAP stands for Subjective, Objective, Assessment, and Plan. The format is common across healthcare, which makes it easy for other providers to scan. It can also work well in a solo or small therapy practice when you want a little more structure around your clinical thinking.
The SOAP format at a glance
| Section | The question it answers | Typical content |
|---|---|---|
| Subjective | What is the client experiencing? | Reported symptoms, concerns, changes, meaningful quotes |
| Objective | What did I directly observe or measure? | Appearance, behavior, affect, speech, engagement, scores |
| Assessment | What is my clinical understanding? | Progress, current needs, functional impact, clinical reasoning |
| Plan | What happens next? | Next-session focus, practice, referrals, frequency, follow-up |
The sections should connect. A concern in Subjective should not disappear by the time you reach the Plan.
S: Subjective
The Subjective section records the client’s view of what is happening. Include symptoms, concerns, meaningful changes, and the way the problem is affecting daily life.
Client reported increased worry about an upcoming performance review and difficulty falling asleep on four nights this week. Client stated, “I keep imagining the worst possible conversation.”
Keep this section focused. It is a summary of what matters to treatment, not a transcript of the client’s week.
Useful prompts:
- What changed since the previous session?
- What symptoms or stressors did the client report?
- How is the concern affecting work, relationships, sleep, or daily functioning?
- Did the client use a skill or complete agreed practice?
O: Objective
The Objective section contains what you directly observed, measured, or verified. This may include relevant parts of the mental status examination, behavioral observations, or screening results.
Client appeared tired and mildly tense. Speech was clear and organized. Affect was congruent with the topics discussed. Client remained engaged and completed the in-session exercise.
Avoid turning an interpretation into an observation. “Client is afraid of success” is a theory. “Client looked away and became quiet when discussing a possible promotion” is observable.
Not every routine note needs a full mental status examination. Include what mattered in this session and whatever your setting requires.
A: Assessment
Assessment is where the note becomes more than a session summary. Connect the reported and observed information to symptoms, functioning, treatment goals, risk when relevant, and your clinical understanding.
Anxiety remains elevated and is disrupting sleep and concentration at work. Client showed growing ability to identify catastrophic thinking but still needed prompts to develop balanced alternatives. Progress toward the coping-skills goal is gradual.
A useful Assessment often includes:
- Current status or change in symptoms
- Effect on functioning
- Progress toward a treatment goal
- Response to the intervention
- Reason continued treatment is useful
- Risk formulation when it was clinically relevant
Avoid simply repeating Subjective and Objective in different words. Explain what the information means for treatment.
P: Plan
The Plan gives the work somewhere to go. Be specific enough that you can open the chart before the next session and know what you intended to do.
Continue weekly CBT-focused therapy. Client will complete one thought record after a work-related anxiety trigger and practice paced breathing before bed on three evenings. Review sleep and preparation for the performance meeting next session.
A Plan can include:
- Session frequency
- Next-session focus
- Between-session practice
- Referrals or coordination of care
- A measure to repeat
- A treatment-plan change
- Follow-up timing
“Continue therapy” is not wrong, but it misses the chance to create a useful bridge to the next session.
Copy-and-use SOAP note template
Reusable template
Complete therapy SOAP note example
The following example is fictional.
Session details: Individual telehealth session, 53 minutes.
Subjective: Client reported increased anxiety after being asked to lead a project at work. Client described difficulty falling asleep, irritability with their partner, and repeated thoughts that a mistake would lead to losing the job. Client completed one breathing practice during the week and said it briefly reduced physical tension.
Objective: Client appeared tired and tense at the start of the session. Speech was clear, coherent, and future-oriented. Client identified three automatic thoughts and actively participated in a cognitive restructuring exercise. Affect softened as the session progressed.
Assessment: Work-related anxiety continues to affect sleep and the client’s relationship. Client is becoming more aware of catastrophic thinking and was able to create a balanced alternative with moderate prompting. Early progress is visible, though the client needs further practice using the skill outside sessions.
Plan: Continue weekly CBT-focused sessions. Client will complete one thought record and use paced breathing before bed on at least three nights. Next session will review sleep, work anxiety, and the outcome of the project meeting.
A shorter SOAP note example
SOAP notes do not always need four long paragraphs.
S: Client reported improved mood and completed two planned social activities. Continued difficulty starting household tasks.
O: Client appeared more energetic than in the previous session and engaged readily in planning. PHQ-9 decreased from 13 to 9.
A: Depressive symptoms are improving, with better social engagement. Task initiation remains a barrier to daily functioning. Client responded well to breaking tasks into smaller steps.
P: Continue behavioral activation. Client will use a ten-minute start for two household tasks and track mood afterward. Follow up in one week.
Common SOAP note mistakes
Putting everything in Subjective
When Subjective becomes a long narrative, the important clinical information gets buried. Keep the story focused on symptoms, functioning, changes, and treatment-relevant context.
Treating Objective as a second Subjective section
Objective is not another place to summarize what the client said. Record what you observed or measured.
Skipping the clinical reasoning
“Client is still anxious” is a status update, not much of an Assessment. Explain the functional effect, progress, and response to treatment.
Writing a generic Plan
If every note ends with “continue therapy,” the record does not show how treatment is moving. Add one clear next step.
Copying the same note forward
Templates save time. Cloned content creates confusion. Reuse the structure, not last week’s clinical picture.
SOAP note wording examples
| Instead of | Try |
|---|---|
| Client is anxious. | Client reported persistent worry and difficulty sleeping before an upcoming work review. |
| Client was appropriate. | Client was attentive, cooperative, and able to remain engaged throughout the session. |
| Discussed thinking errors. | Used cognitive restructuring to identify catastrophizing related to work performance. |
| Client responded well. | Client identified two thinking patterns and generated one balanced alternative with minimal prompting. |
| Continue therapy. | Continue weekly CBT sessions focused on worry, sleep, and work functioning. |
Use these as models, not stock phrases. The strongest wording describes what actually happened.
When SOAP works especially well
SOAP may be a good fit when:
- You collaborate with medical or multidisciplinary providers.
- You want a visible line between client report and clinician observation.
- Your EHR or organization already uses SOAP.
- You document measurements or medication-related care alongside therapy.
- A four-part structure helps you show clinical reasoning clearly.
If separating Subjective and Objective feels artificial in your work, DAP notes combine them into one Data section. If you want interventions and client responses to stand out, BIRP notes may feel more natural.
Writing SOAP notes faster
- Use the same four headings every time.
- Capture three reminders immediately after the session: concern, intervention, next step.
- Keep a short list of intervention verbs such as assessed, practiced, modeled, clarified, and reviewed.
- Build separate templates for common session types rather than one enormous template.
- Dictate a brief session summary, then organize it into SOAP while the details are fresh.
Apollo Notes can turn a spoken, typed, recorded, or handwritten summary into a SOAP draft for you to review and edit. Try Apollo Notes for free.
Frequently asked questions
How long should a therapy SOAP note be?
Long enough to show the concern, observations, clinical understanding, and plan. A routine outpatient note may be a few focused paragraphs. A complex or high-risk session may need more detail.
Where do interventions go in a SOAP note?
Therapists often describe the intervention in Objective or Assessment, depending on the template. The important thing is that the intervention, client response, and treatment connection are easy to find.
Where does risk assessment go?
Relevant findings may appear in Subjective and Objective, with your overall risk formulation and response in Assessment and Plan. Follow the structure required by your setting.
Can SOAP notes use bullet points?
Yes, if the note stays clear and your organization allows it. Many clinicians use short bullets in Subjective and Objective, then a sentence or two for Assessment and Plan.
Are SOAP notes better than DAP notes?
Not universally. SOAP creates a clear four-part record. DAP is more compact. The best format is the one that meets your requirements and helps you document consistently.