In professional counseling and psychotherapy, maintaining accurate and organized session notes is both an ethical obligation and a clinical necessity. The SOAP note—an acronym for Subjective, Objective, Assessment, and Plan—is one of the most widely used documentation formats in mental health settings. It helps counselors track progress, make informed clinical decisions, and ensure legal and insurance compliance.
This guide provides a complete SOAP note example along with explanations for each section to help counselors, interns, and students create clear, concise, and clinically useful documentation.
1. What Is a SOAP Note?
A SOAP note is a structured format used by mental health professionals to summarize each counseling session. It ensures consistency and supports:
- Progress tracking
- Clinical decision-making
- Communication between providers
- Insurance and billing documentation
- Legal protection through accurate records
Each letter in the acronym represents a different section of the note:
- S – Subjective: Client’s verbal report and personal experience
- O – Objective: Observable behavior, clinical findings, or assessments
- A – Assessment: Counselor’s clinical interpretation
- P – Plan: Next steps, homework, referrals, or changes in treatment
2. SOAP Note Example for Counseling
Here is a complete and realistic SOAP note example for a fictional adult counseling session:
Client Name: Jane Doe
Date: May 1, 2025
Session #: 4
Counselor: John Smith, LPC
Duration: 50 minutes
S – Subjective:
Client reports feeling “overwhelmed and drained” at work, citing increased responsibilities and poor work-life balance. She states, “I’m constantly anxious and can’t turn my brain off at night.” Sleep has been reduced to 4–5 hours per night. Client denies substance use and reports continued use of grounding techniques from the last session.
O – Objective:
Client appeared fatigued, with slowed speech and occasional sighing. She maintained eye contact and engaged in session with full attention. Affect was flat but appropriate to context. No signs of psychosis or suicidal ideation were present.
A – Assessment:
Client continues to exhibit symptoms consistent with Generalized Anxiety Disorder (GAD), including excessive worry, restlessness, and sleep disturbances. She demonstrates insight into her symptoms and appears motivated to apply coping strategies. Progress is moderate, with improved emotional awareness but persistent stress triggers.
P – Plan:
- Continue CBT framework to address cognitive distortions
- Introduce time management and boundary-setting tools in next session
- Assign journaling task focused on identifying workplace stressors
- Evaluate sleep hygiene practices at the following session
- Weekly sessions to continue
3. Tips for Writing Strong SOAP Notes
- Be concise yet specific: Avoid vague language—document direct quotes or observable behaviors.
- Use clinical language: Terms like “affect,” “presenting issue,” and “therapeutic goal” improve clarity.
- Maintain objectivity: Only the “S” section reflects client perspective. Avoid inserting opinions in other sections.
- Ensure compliance: Make sure notes align with your licensing board and agency requirements.
- Store securely: All SOAP notes should be stored in HIPAA-compliant systems.
4. When Are SOAP Notes Used in Counseling?
SOAP notes are commonly used in:
- Private practice
- Community mental health clinics
- School counseling
- Hospital-based behavioral health units
- Internship and clinical supervision
They are often reviewed during audits, insurance billing reviews, and supervision.
Writing clear and consistent SOAP notes is essential for ethical counseling practice and effective client care. By using a structured format, counselors can track therapeutic progress, collaborate with other professionals, and uphold standards in mental health documentation. Whether you’re a student, intern, or licensed professional, mastering SOAP notes helps strengthen both clinical insight and professional accountability.