Sample SOAP Note for a GAD Therapy Session
A 50-minute CBT session with a client working on intolerance of uncertainty. This is the shape most insurers expect when you bill a psychotherapy code: intervention, response, and measurable movement.
Fictional composite for training and comparison. Not a real client record and not clinical advice.
Write mineSubjective
- Client reported a difficult week following a performance review, with persistent worry about job security. - Described difficulty falling asleep three of seven nights, and one episode of calling in sick to avoid a team meeting. - Identified "if I make one mistake they will manage me out" as the most distressing cognition of the week. - Denies suicidal ideation and self-harm; reports no intent to harm others.
Objective
- Presented appropriately groomed, cooperative. Speech slightly pressured when discussing work. - Affect anxious, reactive; settled over the course of the session. - Completed a thought record in session on the performance-review cognition. Initial believability 90/100, reduced to 45/100 after identifying the cognitive distortion (catastrophising) and reviewing two disconfirming experiences from the past year. - Engaged with behavioural experiment planning without prompting.
Assessment
- Generalized anxiety disorder, active, with symptom intensity above baseline this week in the context of a workplace stressor. - Demonstrates good cognitive flexibility within session — believability of the hot thought reduced by half. - Avoidance behaviour (calling in sick) emerging; needs targeting before it consolidates. - Progress toward goal 2 (reduce avoidance of work meetings) is partial. - Risk: low. No ideation, plan, or intent; strong engagement and social support.
Plan
- Continue weekly CBT with a focus on intolerance of uncertainty. - Homework: one thought record daily, plus a graded exposure — attend one full team meeting this week without leaving early. - Schedule the exposure for the lowest-anxiety meeting first; client will log anticipatory anxiety rating before and after. - Review thought records and exposure log at the next session. - Next session scheduled for next Tuesday at 10:00. Return precautions discussed.
What belongs in each section of a psychotherapy SOAP note
Subjective
Anchor the week with concrete events and numbers. "Three of seven nights" and "one episode of calling in sick" are billable, reviewable facts; "client was anxious" is not.
Objective
For therapy notes this section documents what you did and what happened clinically — the intervention, the ratings before and after, the client's engagement. That is what distinguishes a psychotherapy note from a chat.
Assessment
Tie the session back to the treatment plan goals by number where you have them. Insurers look for medical necessity: is the client still impaired, and is the treatment still working?
Plan
Homework must be specific enough to be checkable next week: how often, what exactly, and what the client will record. Note the next appointment date.
Generate this structure from your own notes
The generator takes the same four headings and fills them with your session content — redacted in your browser, editable before you sign, exportable to Word.
Open the generatorCommon questions
What is the difference between a DAP and a SOAP note for anxiety?+
DAP merges subjective and objective into a single "Data" section. If your clinic accepts DAP, it is shorter to write and loses little for a straightforward therapy session — the trade-off is less structure for auditors who expect separated data.
Do progress ratings belong in the note?+
Yes when you have them. "Believability 90 → 45" is objective evidence of clinical work and takes four words.
More sample notes