SOAP Notes for Therapy Template (US)
Solid progress notes support your clinical decisions, protect you in an audit and get your claims paid. Our free SOAP Notes for Therapy template gives you the same structure every session, so documentation takes minutes instead of 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 counseling and psychotherapy, where much of the session content is what the client tells you and how they present.
This template adds what therapy sessions and insurers need that a generic SOAP note leaves out: session number, format, ICD-10 diagnosis and CPT code, a structured risk assessment, and your license 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 did with homework. Short direct quotes are valuable because they capture the client's own framing.
Example: Client reports a "better couple of weeks." 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, behavior, and engagement
- Mood (as reported) and affect (as observed)
- Speech, thought process and content, and perception
- Standardized measures such as the PHQ-9 or GAD-7, compared with intake
- For telehealth: the platform, the client's location, and identity verification
Keep this section factual. Interpretation belongs in the assessment.
Assessment
Your clinical reasoning. Bring the subjective and objective information together to state the diagnosis, how the client is progressing toward treatment plan goals, and what is helping or getting in the way. For insured clients, this is also where you document medical necessity: the symptoms and functional impairment that justify continued treatment at the current level of care.
Plan
What happened in session and what happens next:
- Interventions used (e.g. cognitive restructuring, behavioral experiments, grounding)
- Homework agreed with the client
- Updates to treatment plan goals
- Referrals or coordination with other providers
- Frequency and date of the next session
Risk assessment
Every session note should show that risk was assessed. Check the level you've assessed and briefly note the basis: suicidal or homicidal ideation, intent, plan, protective factors, and any safety planning. If the client denies SI/HI, record that too.
How to use this template
- Download the PDF. It's US Letter and fillable, so you can type straight into it or print it for handwritten notes.
- Complete the session details. Client name and ID, date, start time and duration, session number, format, ICD-10 code and CPT code.
- Work through S, O, A, and P. Write the note as soon as possible after the session, while the details are fresh.
- Record the risk assessment. Check a level and add a brief note, even when no risk was identified.
- Sign and store securely. Add your signature, license number, and the date, then file the note in your EHR or practice management system.
Who can use this template?
The template suits any US clinician providing psychotherapy, including:
- Licensed professional counselors (LPC, LMHC)
- Licensed clinical social workers (LCSW)
- Licensed marriage and family therapists (LMFT)
- Psychologists (PhD, PsyD)
- Associates and pre-licensed clinicians working under supervision
Tips for writing therapy SOAP notes
Match the duration to the CPT code. Record the actual start time and duration. 90832, 90834, and 90837 are time-based, and the documented time needs to support the code billed.
Measure what you can. "Anxiety improved" is hard to defend in an audit. "GAD-7 decreased from 16 to 11 since intake" shows progress and supports continued authorization.
Tie every note to the treatment plan. Each intervention should connect to a treatment plan goal, and the assessment should show progress toward it.
Keep psychotherapy notes separate. HIPAA gives extra protection to psychotherapy notes (your private process notes) only when they're kept separate from the clinical record. SOAP progress notes are part of the clinical record.
Store notes securely. Keep notes in a HIPAA-compliant system with a signed business associate agreement, and retain them for the period your state requires.
Frequently asked questions
What's the difference between progress notes and psychotherapy notes?
Progress notes, like SOAP notes, document the session for the clinical record: dates, diagnosis, interventions, progress, and plan. Insurers can request them. Psychotherapy notes are your private impressions, kept separately, and HIPAA gives them additional protection.
How long should a therapy SOAP note be?
Most notes fit on one page. Include enough detail to support the diagnosis, the service billed, and medical necessity, without transcribing the session.
Can clients see their therapy notes?
Under HIPAA, clients generally have the right to access their progress notes. Psychotherapy notes are an exception. Write every progress 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 document the platform, the client's physical location, and identity verification. Many payers and states require these details for telehealth claims.