Sample SOAP Note for a Child Play Therapy Session
A 45-minute session with a 9-year-old referred for school refusal, including ten minutes of parent collateral. Note how the note names the guardian and documents consent without turning into a family session.
Fictional composite for training and comparison. Not a real client record and not clinical advice.
Write mineSubjective
- Client (age 9) presented with guardian for a scheduled session. Guardian reported two mornings of crying before school this week, down from four the prior week. - Guardian reported the client asked to bring a comfort object to school on both occasions and was permitted to do so. - Client, when asked directly, said school "is boring and my stomach hurts", and identified recess as the best part of the day. - No safety concerns reported by guardian. No new medical concerns.
Objective
- Client separated from guardian without distress, engaged readily in the playroom. - During directive play, reenacted a school-morning sequence with figures, assigning the child figure the line "I don't want to go" and having the adult figure stay home. - Affect bright when play was self-directed, flat when the sequence turned to separation. - Therapist reflected the theme and introduced a coping phrase ("one step at a time"), which the client repeated and used twice unprompted later in the session. - Attention and frustration tolerance age-appropriate. No aggressive behaviour toward materials or therapist.
Assessment
- Separation-related anxiety, continuing, with a modest reduction in school-refusal mornings this week. - Play themes consistent with the presenting concern; client is able to symbolise the separation conflict and accept a coping strategy within session. - Guardian is implementing accommodations consistently; comfort-object use appears to be reducing distress without reinforcing avoidance. - Progress toward goal 1 (attend school full week) is partial. - Risk: no indicators of abuse or neglect observed; nothing to report at this time.
Plan
- Continue weekly play therapy; next session in 7 days. - Provide guardian with a visual morning routine to use on school days. - Guardian to continue permitting the comfort object and to log school mornings on the provided sheet. - Review the log at the next session and adjust the school-reintegration plan with the guardian. - Coordination with school counsellor to be discussed with guardian at the next session, pending consent.
What belongs in each section of a psychotherapy SOAP note
Subjective
With minors, the guardian's report and the child's own words are separate sources and should be distinguishable in the text. Attribute each one.
Objective
Describe the play concretely: what the client did, what figures said, when affect shifted. That detail is the evidence base for the assessment and it is what a supervisor can actually review.
Assessment
For child cases, state the risk screen explicitly and in the negative when appropriate — "no indicators observed; nothing to report" protects you and satisfies mandated-reporting documentation.
Plan
Split the plan by actor: what you will do, what the guardian will do, what needs consent before it happens. Parent collateral should appear as a discrete line, not be folded into the session.
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
Should the child's name appear in the note?+
Use an identifier your practice policy specifies, and keep it consistent. The clinical content — what was said and done — matters more than the name, and it is what should never be missing.
How do I document parent collateral in a SOAP note?+
As its own bullet in Subjective (guardian report) and its own line in Plan (what the guardian will do). If the collateral ran long enough to bill separately, it usually needs its own note.
More sample notes