SOAP note example for therapy: Subjective, Objective, Assessment, Plan
Updated October 8, 2026 by madebykamal
A SOAP note is a four-part progress note: Subjective (what the client reports), Objective (what you observe or measure), Assessment (your clinical interpretation) and Plan (what happens next). The structure, developed by Larry Weed, is used across healthcare professions, including mental health counseling, and its standard order lets clinicians in other specialties read your notes easily. Below is what goes in each section, a complete mental health example with an invented client and a template you can copy.
General information, not medical advice. How these guides are made.
What goes in each section of a SOAP note
These descriptions follow StatPearls on NCBI Bookshelf, the Purdue OWL and SimplePractice. Purdue notes that the ideal format differs between fields and workplaces, so treat this as the common shape, not a fixed rule.
- Subjective: what the client, or someone close to them, reports. That includes the chief concern, symptoms, progress since the last session and relevant history. Purdue suggests quoting key phrases rather than long passages.
- Objective: what you observed or measured, the things anyone watching could agree happened, such as appearance, behavior and mood in session, scores on measures and data on therapy goals. StatPearls flags a common mistake: a symptom the client describes belongs in Subjective, a sign you observe in Objective.
- Assessment: your synthesis of the Subjective and Objective information: clinical impression, progress compared with earlier sessions, what worked and what did not, and diagnosis where relevant. Purdue warns against writing anything you cannot support with evidence.
- Plan: the next session, goals for you and the client before then, homework, referrals, changes to treatment and interventions you plan to use.
A complete SOAP note example (invented client)
The client, details and scores below are invented for illustration.
- Subjective: Client attended a 50 minute individual in-person session for ongoing treatment of depression. Client rated mood 4 out of 10, up from 3 last session, and said, "I made it to the gym twice, which I haven't done in months." Client reported sleeping 9 to 10 hours a night and completed 4 of 7 scheduled activities. Client denied suicidal ideation, intent or plan.
- Objective: Client arrived on time, casually dressed, with good hygiene. Movements were slowed early in the session. Speech was soft, with normal rate. Affect was constricted and brightened when describing the gym visits. PHQ-9 score was 13, down from 17 four weeks ago.
- Assessment: Client shows early improvement in depressive symptoms, supported by the lower PHQ-9 score and partial completion of the activity schedule. Mood was higher on days with planned activity, which supports continuing behavioral activation. Oversleeping remains a barrier. No current safety concerns identified.
- Plan: Therapist reviewed the activity schedule and problem-solved the missed activities. Next session in one week. Homework: schedule five activities, two with another person, and rate mood before and after each. Introduce a consistent wake time next session. Repeat the PHQ-9 in two weeks and continue the current treatment plan.
A SOAP note template for therapy sessions
- Subjective: Session type and length [ ]. Reason for the session [ ]. Client report since last session, with brief quotes [ ]. Symptoms, sleep and functioning [ ]. Homework completed [ ]. Risk screening, in the client's words [ ].
- Objective: Appearance and behavior [ ]. Speech, mood and affect as observed [ ]. Measures and scores [ ]. Data on therapy goals [ ].
- Assessment: Progress toward goal [goal]: [ ]. Clinical impression, tied to S and O [ ]. Barriers [ ]. Risk level [ ].
- Plan: Interventions used today [ ]. Next session [date]. Homework [ ]. Referrals or coordination [ ]. Treatment plan changes [ ].
SOAP vs DAP vs BIRP
All three are progress note formats. A DAP note (Data, Assessment, Plan) combines the Subjective and Objective sections into one Data section, which SimplePractice says helps clinicians write notes faster. A BIRP note (Behavior, Intervention, Response, Plan) gives your interventions and the client's response their own sections; SimplePractice describes BIRP as focused on the session's theme, tone and the client's behavior, and SOAP as more objective. Our DAP note example and BIRP note example pages walk through those formats.
Purdue notes that formats differ between workplaces, and SimplePractice adds that state board documentation rules vary. This page is general information, not clinical or legal advice, so follow the format and rules your agency and state board set.
Tips for writing SOAP notes faster
- Write the note soon after the session, from brief personal notes, rather than during it or long afterward (Purdue).
- Keep the client's words in Subjective and your observations in Objective.
- Describe behavior, not labels: Purdue prefers "grimaced and sighed repeatedly" to "very frustrated".
- Be concise. StatPearls notes that the more succinct yet thorough a SOAP note is, the easier it is to review and use.
- Tie the Assessment to a named treatment plan goal.
- Start from a template, so you fill in fields instead of facing a blank page.
Writing SOAP notes on an iPhone
If you write notes on an iPhone, NoteKey is a keyboard that expands SOAP, DAP, BIRP and GIRP note templates with fill-in fields in any app, including your EHR. You tap through the fields while a progress chip shows where you are in the note, and its autocorrect protects medication names and instruments such as PHQ-9 and GAD-7. NoteKey does not record sessions, has no AI scribe and its templates contain no clinical advice, so the content stays your clinical judgment.
Questions people ask
What does SOAP stand for in a therapy note?
Subjective, Objective, Assessment, Plan. Subjective is what the client reports, Objective is what you observe or measure, Assessment is your clinical interpretation of both, and Plan is what happens next.
What goes in the objective section of a mental health SOAP note?
What you observed or measured in the session, such as appearance, behavior and mood, scores on measures and data on therapy goals. Anything the client tells you, including symptoms they describe, belongs in the Subjective section.
Is a SOAP note the same as a psychotherapy note?
Not in the HIPAA sense. HIPAA defines psychotherapy notes as notes documenting or analyzing the contents of a counseling session that are kept separate from the rest of the record, and it excludes test results, treatment modalities and any summary of diagnosis, treatment plan, symptoms and progress to date. Those are the items a SOAP progress note records. This is general information, not legal advice.
Related
- DAP Note Example for Therapy, With a Template
- BIRP Note Example for Mental Health, With a Template
- Best apps for writing therapy notes faster in 2026
- Therapy Notes Keyboard NoteKey
Sources
- https://www.ncbi.nlm.nih.gov/books/NBK482263/
- https://owl.purdue.edu/owl/subject_specific_writing/healthcare_writing/soap_notes/index.html
- https://owl.purdue.edu/owl/subject_specific_writing/healthcare_writing/soap_notes/major_sections.html
- https://owl.purdue.edu/owl/subject_specific_writing/healthcare_writing/soap_notes/soap_note_tips.html
- https://www.simplepractice.com/resource/how-to-write-soap-notes/
- https://www.simplepractice.com/resource/how-to-write-dap-notes/
- https://www.simplepractice.com/resource/how-to-write-birp-notes/
- https://www.law.cornell.edu/cfr/text/45/164.501