Standard SOAP Note
Classic SOAP format for general therapy sessions
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Edit & DownloadSubjective
Client reports feeling [emotion] and describes [situation]. Client states [direct quote if relevant]. Client appears [appearance/behavioral observations].
Objective
Client presents with [mood/affect]. Speech is [rate/volume/quality]. Thought process is [linear/tangential/etc]. Insight and judgment appear [level]. No suicidal/homicidal ideation reported.
Assessment
Client continues to work on [goals]. Progress noted in [specific areas]. Areas for continued focus include [specific challenges]. Diagnosis: [if applicable].
Plan
Continue weekly sessions. Focus on [specific interventions]. Assign homework: [specific tasks]. Next session scheduled for [date].
How to Use This Template
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1
Review the template structure
Familiarize yourself with the sections and their purposes before your session.
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2
Customize for your practice
Click "Edit & Download" to modify the template to fit your specific needs and clinical approach.
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3
Save and reuse
Download as PDF for immediate use, or use within HIPAAtherapy to auto-fill client details and save to your records.
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SOAP format specifically designed for Cognitive Behavioral Therapy
Trauma-Informed SOAP Note
SOAP format with trauma-sensitive language and safety considerations
DBT SOAP Note
SOAP format for Dialectical Behavior Therapy sessions