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SOAP Note Examples for Mental Health
Three illustrative SOAP note examples — an initial intake, a couples follow-up, and a session with a documented risk consideration.
Updated August 29, 2026 · 6 min read
These are illustrative SOAP note examples for common outpatient mental health scenarios. Each is a teaching example, not a template to copy verbatim — a real note should reflect the actual session, client, and your own clinical judgment. See How to Write SOAP Notes → for a full breakdown of what belongs in each section.
Example 1 — Initial intake session
S: Client, 34, self-referred, reports 'constant worry' over the past six months, worse since a recent job change. Describes difficulty concentrating at work and frequent tension headaches. Denies prior mental health treatment. No current safety concerns reported.
O: Alert, oriented x4, cooperative and engaged throughout. Affect anxious but reactive. Speech normal rate. GAD-7 administered: score 15. PHQ-9 administered: score 6.
A: Presentation and GAD-7 score consistent with moderate-severe generalized anxiety, situationally exacerbated by recent occupational change. PHQ-9 score does not suggest significant depressive symptoms at this time. No indication of acute risk. Client is a good candidate for CBT-based intervention targeting worry patterns.
P: Begin weekly sessions. Provide psychoeducation on the anxiety cycle. Introduce basic diaphragmatic breathing as a first coping tool. Reassess GAD-7 and PHQ-9 at 4-session intervals. No referral indicated at this time.
Example 2 — Routine follow-up, couples context
S: Both partners attended. Client A reports 'things have been better' since implementing the communication check-in discussed last session, used it twice this week. Client B agrees there's been 'less tension' but raises a specific disagreement about weekend plans that escalated Tuesday.
O: Both partners engaged, made eye contact with each other during the discussion of Tuesday's disagreement. Tone remained calm throughout, no escalation observed in session.
A: Continued progress on primary treatment goal (reducing communication breakdown). Tuesday's disagreement appears to be a normal conflict handled with more skill than reported prior to treatment — both partners de-escalated without the check-in tool, a sign of generalization of the skill beyond the structured exercise.
P: Continue biweekly couples sessions. Process the Tuesday disagreement in more depth next session as a case example of applied skills. No change to treatment plan.
Example 3 — Session with a risk consideration documented
S: Client reports a 'really bad week,' describing increased hopelessness following a recent relationship ending. States she has had 'thoughts that things would be easier if I wasn't here' but denies any plan or intent, and denies access to means. Reports her support system (sister, close friend) is aware and available.
O: Affect congruent with reported distress, tearful at points but able to re-engage. No psychomotor agitation or retardation observed. PHQ-9 administered: score 19 (up from 11 two weeks prior), with item 9 (thoughts of self-harm) endorsed at 'several days.'
A: PHQ-9 increase and passive ideation without plan or intent, in the context of an acute stressor (relationship loss). Protective factors present and engaged (support system, no access to means, denies intent). Risk assessed as elevated but not acute at this time — clinical judgment supports continued outpatient management with increased monitoring rather than immediate higher level of care, based on the full clinical picture in this session.
P: Safety plan reviewed and updated collaboratively with client. Increased session frequency to twice weekly for the next two weeks. Client provided crisis line number and instructed to contact if ideation escalates or a plan emerges. Sister/support system confirmed as aware. Reassess at next session; consult with supervisor prior to next session given risk elevation.
FAQ
- Can I copy a SOAP note example directly into my chart?
- No — examples are teaching tools to show structure and reasoning. A real note should reflect the actual session, client, and your own clinical judgment, not a copied template.
- How should risk be documented in a SOAP note example?
- Risk should be documented explicitly whenever it's a clinical consideration, with the Assessment explaining the reasoning behind the risk level determined and the Plan documenting concrete safety and follow-up steps — not left implicit or vague.
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