SOAP Notes for Therapists: Templates & Best Practices

SOAP notes (Subjective, Objective, Assessment, Plan) are the most widely used clinical documentation format in mental health and therapy settings. This guide covers how to write SOAP notes for therapists and counsellors, SOAP note templates for mental health, real SOAP note examples, and how SOAP compares to DAP notes and BIRP notes.

What Are SOAP Notes?

SOAP notes are a structured clinical documentation format used by therapists, psychologists, social workers, and other healthcare providers to record patient sessions. SOAP is an acronym for the four sections of the note:

• Subjective (S), what the patient reports (mood, symptoms, stressors, quotes)
• Objective (O), measurable observations and standardized scores (PHQ-9, GAD-7, affect, behavior)
• Assessment (A), clinical interpretation, diagnosis, progress, and risk level
• Plan (P), next steps, interventions, referrals, next appointment

SOAP notes originated in medicine, developed by Dr. Lawrence Weed in the 1960s, and have since become the most widely used documentation format in mental health settings across North America.

S, Subjective Section

The Subjective section captures the patient's perspective, what they report about their current state, in their own words. This is the patient's narrative, not the clinician's interpretation.

What to include in the S section:

• Presenting mood and affect as reported by patient
• Sleep quality, duration, and disturbances
• Appetite and weight changes
• Social functioning and interpersonal stressors
• Significant events or changes since last session
• Medication adherence and side effects
• Substance use (if relevant)
• Homework completion and reflection
• Direct patient quotes for significant statements

O, Objective Section

The Objective section contains measurable, observable data, information that is reproducible and not dependent on clinical interpretation. In mental health settings, this is where standardized assessment scores go.

What to include in the O section:

• Standardized assessment scores (PHQ-9, GAD-7, PCL-5, AUDIT, DAST-10) with severity classification
• Score change from previous administration
• Mental status exam (MSE) components: appearance, behavior, speech, mood, affect, thought process, thought content, cognition, insight, judgment
• Eye contact, psychomotor activity, grooming
• Toxicology or breathalyzer results
• Attendance and session structure
• Collateral information from family or other providers

A, Assessment Section

The Assessment section is where the clinician synthesizes the subjective and objective data into a clinical interpretation. This is the clinician's professional judgment, not just a restatement of facts.

What to include in the A section:

• DSM-5-TR diagnosis with ICD-11 code(s)
• Clinical impression of current presentation
• Progress toward treatment goals
• Interpretation of assessment scores in clinical context
• Risk assessment: suicidal ideation, self-harm, risk level
• Protective factors (social support, coping skills)
• Barriers to treatment or progress

P, Plan Section

The Plan section outlines the next steps for treatment. It should be specific and action-oriented.

What to include in the P section:

• Next session: date, time, frequency
• Therapeutic interventions planned for next session
• Between-session tasks / homework assigned
• Assessments to administer at next visit
• Referrals or consultations initiated
• Medication coordination
• Crisis plan updates
• Coordination with other providers

SOAP Note Template for Mental Health

Use this template as a starting point for individual therapy session SOAP notes.

S, Subjective Patient presents reporting mood/affect. Sleep: hours/quality. Appetite: changes. Social functioning: notes. Significant events: list. Homework: status. Patient states: "quote".

O, ObjectiveAssessment scores. Patient arrived on time, appropriate appearance. Eye contact appropriate. Speech normal. Mood per patient. Affect congruent. Thought process linear. Thought content no psychosis. Insight good. Judgment intact.

A, AssessmentICD-11 code DSM-5-TR Diagnosis. Clinical impression: summary. PHQ-9 reflects severity; status from baseline. Progress toward Goal #: status. Risk: status. Risk level: Low/Mod/High.

P, Plan Continue modality on frequency. Next session: date. Interventions: planned. Homework: task. Repeat PHQ-9 at next session. Referrals/Coordination.

SOAP vs DAP vs BIRP

Choose SOAP if you use standardized outcome measures (PHQ-9, GAD-7, etc.), work in a multidisciplinary setting, or bill insurance that requires structured documentation.