Standard SOAP Note

Client reports feeling [emotion] and describes [situation]. Client states [direct quote if relevant]. Client appears [appearance/behavioral observations].

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.

Client continues to work on [goals]. Progress noted in [specific areas]. Areas for continued focus include [specific challenges]. Diagnosis: [if applicable].

Continue weekly sessions. Focus on [specific interventions]. Assign homework: [specific tasks]. Next session scheduled for [date].

Client reports feeling "worn down and anxious most of the week" and describes ongoing conflict with a coworker. Client states, "I keep replaying the conversation in my head at night." Client appeared tired but engaged throughout the session.

Client presents with anxious mood and congruent affect. Speech is normal in rate and volume. Thought process is linear and goal-directed. Insight and judgment appear good. No suicidal or homicidal ideation reported.

Client continues to work on managing workplace anxiety using cognitive restructuring. Progress noted in identifying automatic thoughts in the moment. Continued focus needed on sleep hygiene and assertive communication. Diagnosis: Adjustment disorder with anxiety (F43.22).

Continue weekly sessions. Focus on assertiveness skills and thought challenging. Assign homework: complete one thought record after any work conflict and practice a nightly breathing exercise. Next session scheduled for the same time next week.