Trauma-Informed SOAP Note
SOAP format with trauma-sensitive language and safety considerations
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Edit & DownloadSubjective
Client reports feeling [emotion] and describes [situation]. Client notes [triggers if any]. Safety assessment: [current safety status]. Client's window of tolerance appears [stable/compromised].
Objective
Client presents with [mood/affect]. Signs of [hypervigilance/dissociation/etc] noted. Grounding techniques [effective/needed]. Client demonstrates [coping skills].
Assessment
Client continues trauma processing work. Progress in [specific areas]. Triggers identified: [list]. Continued focus on [safety/stabilization/processing].
Plan
Continue trauma-informed approach. Practice [specific grounding/coping techniques]. Safety plan reviewed/updated. Next session: [specific focus].
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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