Free template

SOAP note template for therapy sessions

By Albert Wong, PhD, Clinical Psychologist

SOAP — Subjective, Objective, Assessment, Plan — is the oldest and most widely recognized progress-note format in healthcare. It was built for medical charting, and that is both its strength and its friction for therapists: every physician, nurse, and auditor can read a SOAP note without explanation, but the Subjective/Objective split takes a little translation for talk therapy, where the session is mostly conversation.

The translation that works: Subjective holds what the client tells you — symptoms, concerns, progress in their words. Objective holds what you observe — appearance, affect, engagement, mental-status impressions, and any measure scores. Assessment is where you get to be a clinician: how the two fit together, progress against the treatment plan, risk, and diagnosis. Plan says what happens next.

SOAP is the right choice when you share charts with medical providers (integrated care, hospital systems, psychiatry collaboration), when your agency standardizes on it, or when you simply want the format least likely to need explaining to anyone. If the S/O split feels like busywork for your setting, see the DAP template — it merges those two sections — or the format comparison.

The template

Plain text — paste into any EHR or document

SOAP PROGRESS NOTE

Client name: ____________________   Date of service: ____________
Start / end time: _______________   CPT code: ____________
Clinician: ______________________   Location / modality: ____________

S — SUBJECTIVE
The client's own report: concerns, symptoms, and progress since the
last session, with short direct quotes where clinically meaningful.
- Presenting concerns today:
- Reported symptoms (frequency / intensity / duration):
- Progress or setbacks since last session:
- Relevant stressors or life events:

O — OBJECTIVE
What you observed — factual and free of interpretation.
- Appearance, behavior, and engagement:
- Mood and affect as observed:
- Speech, thought process, orientation:
- Response to interventions during session:
- Measure scores administered today (e.g., PHQ-9, GAD-7), if any:

A — ASSESSMENT
Your clinical interpretation: how the subjective and objective
sections fit together.
- Progress toward treatment plan goals:
- Clinical impressions / current symptom severity:
- Risk assessment (suicidal or homicidal ideation: denied /
  present — if present, document assessment and action taken):
- Diagnosis (confirmed / updated):

P — PLAN
- Interventions planned for next session:
- Homework or between-session practice assigned:
- Referrals, care coordination, or consultation:
- Next appointment:

Clinician signature / credentials: ____________  Date signed: ________

A filled example

"Jamie A." is a fictional client — every detail below is invented and deliberately generic. Never copy identifying details from real charts into templates or samples.

Fictional example — for structure, not content

SOAP PROGRESS NOTE — FILLED EXAMPLE (fictional client)

Client name: Jamie A. (fictional)   Date of service: 03/12/2026
Start / end time: 10:00 - 10:53     CPT code: 90834
Clinician: R. Torres, LCSW          Location / modality: Office, in person

S — SUBJECTIVE
Jamie reported feeling "less on edge" this week, rating anxiety 4/10
compared with 6/10 last session. Described one difficult day after a
tense team meeting at work but stated the paced-breathing exercise
"actually helped this time." Reported sleeping 6-7 hours most nights,
an improvement from earlier this month. Denied new stressors.

O — OBJECTIVE
Arrived on time, casually dressed, adequately groomed. Cooperative and
engaged throughout. Mood appeared mildly anxious early in session;
affect was full-range and congruent, brightening when describing use
of coping skills. Speech normal in rate and tone; thought process
linear; oriented x4. Participated actively in cognitive restructuring
exercise. GAD-7 administered: score 8 (mild), down from 11.

A — ASSESSMENT
Jamie continues to make steady progress on treatment goal 1 (reduce
generalized anxiety symptoms). Independent use of breathing skills in
a real workplace trigger situation marks a gain over last month, when
skills were used only in session. Symptoms remain consistent with the
existing diagnosis; severity trending down per GAD-7. Denied suicidal
and homicidal ideation; no risk indicators observed.

P — PLAN
Continue weekly individual CBT. Next session: begin thought-record
review of workplace situations. Homework: complete one thought record
after any anxiety spike above 5/10; continue nightly wind-down
routine. No referrals needed at this time.
Next appointment: 03/19/2026, 10:00.

Clinician signature / credentials: R. Torres, LCSW   Date signed: 03/12/2026

Making each section pull its weight

Subjective: lead with change since last session — that is what demonstrates the treatment is doing something. A rating scale in the client's own report ("anxiety 4/10, down from 6/10") gives you trend data for free.
Objective: two or three mental-status observations plus any administered measure. If you use the PHQ-9 or GAD-7, our free PHQ-9 / GAD-7 scorer computes the score and severity band in-session.
Assessment: the section auditors actually read. Name the treatment-plan goal the session served, and state risk explicitly every time — "denied SI/HI" takes four words and answers the question every reviewer asks first.
Plan: concrete and short: next intervention, homework, next appointment. The CPT code you bill should match the session you documented — our CPT code picker walks through the common psychotherapy codes and their time thresholds.

If you'd rather not assemble this from a blank page every session: Practice Harbor's note templates include SOAP out of the box, with AI drafting that writes the first draft from your session for you to review, edit, and sign.

Common questions

Is a SOAP note required by insurance?

No payer we know of mandates the SOAP format by name. What payers require is documentation of medical necessity: that a covered service was delivered on a given date, what you did, how the client responded, and why continued treatment is warranted. SOAP is one well-established way to organize exactly that information — which is why it survives audits well — but a complete DAP, BIRP, or GIRP note documents the same things. Check your own payer contracts and state rules; the format is almost always your call.

What goes in the Objective section of a therapy SOAP note?

Observable facts, not conclusions: appearance, behavior, mood and affect as you observed them, speech, thought process, orientation, engagement, and any measure scores you administered (a PHQ-9 or GAD-7 score is the cleanest objective data a therapy note can carry). "Tearful when discussing work" is objective; "is depressed about work" is an interpretation and belongs in Assessment. If you find your Objective section empty, brief mental-status observations are usually the missing piece.

How long should a SOAP note be?

For a routine session, most clinicians land between a third and two-thirds of a page — a few sentences per section. The note is a clinical record of medical necessity, not a transcript: it should let a colleague (or an auditor) see what happened and why treatment continues, and nothing more. Notes that run multiple pages usually contain process detail that belongs in your separate psychotherapy notes, if you keep them.

SOAP or DAP — which should a private-practice therapist use?

Both are defensible; the practical difference is that DAP merges Subjective and Objective into one Data section, which many therapists find faster and more natural for talk therapy, where the "objective" data is thin compared to a medical visit. SOAP earns its keep when you work alongside medical providers — integrated care, hospital-adjacent settings — because every other discipline in the chart reads SOAP natively. If you never share charts with medical teams and the S/O split feels artificial, use DAP.

Should I include direct client quotes?

Sparingly, and on purpose. A short quote is valuable when the exact words matter clinically — especially statements about risk ("I would never hurt myself, I just want the worry to stop"), treatment engagement, or symptom change. Remember that clients generally have the right to read their records, and notes can be disclosed in legal proceedings, so quote what you would be comfortable having read aloud with the client present.

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This template and guidance are general clinical-documentation education, not legal advice. Documentation requirements vary by state, license type, and payer contract — check yours.

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