SOAP Notes for Therapy Template (Australia)
Good session notes protect your clients, support your clinical reasoning and keep you on the right side of AHPRA and Medicare requirements. Our free SOAP Notes for Therapy template gives you a consistent structure for every session, so documentation takes minutes rather than eating into your evening.
Download the blank, fillable PDF or the completed example below, then read on for guidance on writing each section well.
What are SOAP notes for therapy?
SOAP stands for Subjective, Objective, Assessment and Plan. It's one of the most widely used formats for clinical progress notes, and it adapts well to psychological and counselling work, where much of the session content is what the client tells you and how they present.
This template adds the pieces therapy sessions need that a generic SOAP note leaves out: session number and modality, referral or funding source (such as a GP Mental Health Care Plan), a structured risk assessment and your AHPRA registration number.
Subjective
The client's account of how things have been. Record their presenting concerns, mood, sleep, stressors and anything that has changed since the last session, along with how they went with homework. Short direct quotes are valuable because they capture the client's own framing.
Example: Client reports a "better fortnight". Completed thought records on 5 of 7 days. Rates average anxiety 5/10, down from 7/10 at intake.
Objective
What you observed and measured. In therapy this usually covers:
- Appearance, behaviour and engagement
- Mood (as described) and affect (as observed)
- Speech, thought form and content, and perception
- Outcome measures such as the K10, DASS-21 or PHQ-9, with comparison to baseline
- Homework or worksheets reviewed in session
Keep this section factual. Interpretation belongs in the assessment.
Assessment
Your clinical reasoning. Bring the subjective and objective information together to describe the working diagnosis or formulation, how the client is tracking against their treatment goals, and what is helping or getting in the way. If outcome measures have moved, say what that means clinically.
Plan
What happened in session and what happens next:
- Interventions used (e.g. cognitive restructuring, behavioural experiments, grounding)
- Homework agreed with the client
- Changes to goals or the treatment plan
- Referrals, liaison with the GP or other providers
- Timing of the next session and where it sits in the referral (e.g. session 5 of 10)
Risk assessment
Every session note should show that risk was considered. Tick the level you've assessed and briefly note the basis: ideation, intent, plans, protective factors and any safety planning or escalation. If nothing was identified, record that too.
How to use this template
- Download the PDF. It's A4 and fillable, so you can type straight into it or print it for handwritten notes.
- Complete the session details. Client name and ID, date, time and duration, session number, format (in person, telehealth or phone), referral or funding source and the modality you're using.
- Work through S, O, A and P. Write the note as soon as you can after the session, while the detail is fresh.
- Record the risk assessment. Tick a level and add a brief note, even when no risk was identified.
- Sign and store securely. Add your signature, AHPRA registration number and the date, then file the note in your practice management system.
Who can use this template?
The template suits any Australian clinician delivering talking therapies, including:
- Clinical, counselling and registered psychologists
- Counsellors and psychotherapists (ACA and PACFA members)
- Mental health social workers and occupational therapists providing Better Access services
- Clinicians delivering NDIS psychosocial or behaviour support therapy
- Provisional psychologists, as a consistent format for supervision
Tips for writing therapy SOAP notes
Write for the next reader. Notes may be read by a colleague, a supervisor, the client or, in rare cases, a court. Write clearly, professionally and without judgement.
Measure what you can. "Anxiety improved" is hard to defend. "K10 reduced from 31 to 24 since intake" shows progress and supports a GP progress report.
Link the plan to the assessment. Each intervention should connect to a goal or barrier you've identified.
Keep Better Access requirements in view. Track session numbers against the referral, and note when a GP review or progress report is due.
Store notes securely. Health information is sensitive information under the Privacy Act 1988. Keep notes in a secure system with access controls, and retain them for the period your state or territory requires (commonly at least seven years after the last contact for adults, and longer for children).
Frequently asked questions
Do psychologists in Australia have to keep session notes?
Yes. The Psychology Board of Australia's code of conduct requires psychologists to keep accurate, up-to-date and legible records of each consultation. Other professions have equivalent requirements through their registration board or professional association.
How long should a therapy SOAP note be?
Most notes fit comfortably on one page. Aim for enough detail that another clinician could pick up the client's care, without transcribing the session.
Can clients see their notes?
Under the Australian Privacy Principles, clients generally have a right to access their health records, with limited exceptions. Write every note on the assumption that the client may read it.
Can I use this template for telehealth sessions?
Yes. Select telehealth as the format, and note in the objective section anything relevant about the setting, such as whether the client was in a private space.