Trauma-Informed SOAP Note

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SOAP format with trauma-sensitive language and safety considerations

trauma PTSD safety triggers
SOAP Notes

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S

Subjective

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].

O

Objective

Client presents with [mood/affect]. Signs of [hypervigilance/dissociation/etc] noted. Grounding techniques [effective/needed]. Client demonstrates [coping skills].

A

Assessment

Client continues trauma processing work. Progress in [specific areas]. Triggers identified: [list]. Continued focus on [safety/stabilization/processing].

P

Plan

Continue trauma-informed approach. Practice [specific grounding/coping techniques]. Safety plan reviewed/updated. Next session: [specific focus].

How to Use This Template

  1. 1

    Review the template structure

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  2. 2

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  3. 3

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