Mental Health SOAP Note Examples

SOAP Note: Depression Assessment

Client is a 35-year-old female presenting for follow-up regarding depressive symptoms. Reports feeling "overwhelmed and hopeless" for the past 3 weeks. States she has been experiencing difficulty sleeping (averaging 3-4 hours per night), decreased appetite with 8-pound weight loss, and loss of interest in previously enjoyable activities. Reports crying episodes daily and feeling "like a burden" to her family. Denies current suicidal ideation but acknowledges having passive thoughts of "not wanting to be here." No recent substance use. Currently taking Sertraline 50mg daily as prescribed.

Patient appears well-groomed but tired. Maintains appropriate eye contact throughout session. Speech is soft and slow with delayed responses. Affect is dysthymic with restricted range. Reports concentration difficulties impacting work performance. PHQ-9 score: 16 (moderate-severe depression). GAD-7 score: 12 (moderate anxiety). Vital signs stable.

Major Depressive Disorder, moderate severity (F33.1). Client demonstrates significant depressive symptoms including sleep disturbance, appetite changes, anhedonia, and mood reactivity. Risk factors include work stress and family history of depression. Current medication may need adjustment given symptom severity.

Next Appointment: [Date] for continued therapy and symptom monitoring.

SOAP Note: Anxiety Assessment

28-year-old male reports increased anxiety over past 6 weeks, describing "constant worry about everything." Specific concerns include work performance, financial stability, and health of family members. Reports physical symptoms including muscle tension, restlessness, and fatigue. Sleep onset difficulty due to "racing thoughts." Denies panic attacks but reports feeling "on edge" most days. Previous coping strategies (deep breathing, exercise) providing minimal relief.

Client appears alert and oriented x3. Demonstrates mild psychomotor agitation - frequent position changes, hand wringing. Speech rate slightly elevated. Affect anxious with appropriate mood congruence. No evidence of thought disorder or perceptual disturbances. GAD-7 score: 14 (moderate-severe anxiety). PHQ-9 score: 8 (mild depression).

Generalized Anxiety Disorder (F41.1) with moderate to severe symptoms. Client demonstrates classic GAD presentation with excessive worry, physical tension, and sleep disturbance. Comorbid mild depressive symptoms noted. Good insight and motivation for treatment.

Next Appointment: [Date] to review anxiety management techniques and assess progress.

SOAP Note: PTSD Treatment Session

42-year-old male veteran presenting for PTSD treatment following combat deployment. Reports nightmares 4-5 times per week, hypervigilance in public spaces, and avoidance of crowded areas. Describes intrusive memories triggered by loud noises and military-related media. Sleep averaging 4-5 hours with frequent awakenings. Reports irritability affecting relationships with spouse and children. Currently using alcohol 3-4 drinks daily to "calm nerves."

Veteran appears casually dressed, alert and cooperative. Maintains limited eye contact, frequently scans room environment. Speech clear and goal-directed. Affect restricted with underlying tension. Reports good appetite and stable weight. PCL-5 score: 52 (indicating probable PTSD). AUDIT score: 12 (hazardous drinking pattern).

Post-Traumatic Stress Disorder (F43.10) related to combat trauma. Symptoms include re-experiencing, avoidance, negative mood/cognition changes, and hyperarousal. Comorbid alcohol use disorder, mild severity. Strong therapeutic alliance established with good treatment engagement.

Next Appointment: [Date] for EMDR session focusing on primary trauma memory.

SOAP Note: Crisis Intervention Session

29-year-old male presents to emergency mental health services following expression of suicidal thoughts to family member. Reports feeling "completely hopeless" and states "I can't see any way out." Describes active suicidal ideation with plan involving medication overdose, has access to means (prescription medications at home). Reports trigger event of job loss 2 weeks ago, compounded by relationship ending 1 month prior. Denies substance use in past 24 hours. Reports minimal sleep (2-3 hours nightly) and has not eaten in 2 days.

Patient appears disheveled, poor eye contact, psychomotor retardation evident. Speech is soft, slow, and monotone. Affect severely depressed with restricted range. Thought process goal-directed but slow. Reports active suicidal ideation 8/10 intensity with specific plan and means. Denies homicidal ideation. Orientation intact to person, place, time. Memory and concentration impaired secondary to depression. Columbia Suicide Severity Rating Scale: High risk (active ideation with plan and means). PHQ-9 score: 22 (severe depression).

Major Depressive Episode, severe with suicidal features (F32.2). Patient presents with acute suicide risk requiring immediate intervention. Precipitating stressors include recent job loss and relationship termination. Limited protective factors identified - has concerned family member who brought him to treatment. No history of previous suicide attempts but current risk factors significantly elevated.

Risk Level: IMMINENT - Requires immediate intervention and continuous monitoring

Next Contact: Within 24 hours or immediately if risk increases.

SOAP Note: Substance Use Assessment

45-year-old female self-referred for alcohol use assessment after family intervention. Reports drinking "more than I should" for past 18 months, escalating after divorce finalization. Current pattern: 4-6 drinks daily (wine), binge drinking on weekends (8-12 drinks). Reports morning shakes requiring alcohol to stop, blackouts 2-3 times monthly, and unsuccessful attempts to cut down. Work performance declining, missed 5 days last month due to hangovers. Family relationships strained. Denies other substance use. Last drink: 8 hours ago.

Patient appears well-groomed but anxious. Mild hand tremors observed, no other withdrawal signs currently present. Speech clear and goal-directed. Mood dysthymic, affect anxious. Cooperative with assessment. Vital signs: BP 145/92, HR 98, appears slightly diaphoretic. AUDIT score: 18 (hazardous drinking). CIWA-Ar score: 4 (mild withdrawal symptoms). Liver function tests pending. Reports 15-pound weight loss over 6 months.

Alcohol Use Disorder, moderate severity (F10.20). Patient meets 6 DSM-5 criteria including tolerance, withdrawal symptoms, unsuccessful attempts to cut down, and continued use despite social consequences. Currently experiencing mild withdrawal symptoms but medically stable. High motivation for treatment following family intervention. No current evidence of alcohol-induced medical complications but requires monitoring.

Next Appointment: [Date] for medication management and treatment progress review.

SOAP Note: CBT Cognitive Restructuring Session

32-year-old female in session 6 of CBT for GAD. Reports significant progress identifying automatic thoughts and cognitive distortions over past 2 weeks. Completed thought records daily as assigned. Primary focus today on catastrophic thinking patterns related to work presentations. States "I keep thinking I'll be fired if I make any mistake" and "Everyone will think I'm incompetent." Reports using deep breathing techniques with moderate success. Anxiety levels decreased from 8/10 to 5/10 average this week.

Patient appears engaged and motivated. Good eye contact, appropriate affect. Demonstrates clear understanding of cognitive model and relationship between thoughts, feelings, and behaviors. Accurately identifies cognitive distortions including catastrophizing, mind reading, and all-or-nothing thinking. Shows progress in challenging negative automatic thoughts. Homework completion 100% this week. Presents thought record with 5 documented situations and alternative thoughts developed.

Generalized Anxiety Disorder (F41.1) - responding well to CBT interventions. Patient demonstrates strong grasp of cognitive restructuring techniques and is applying skills between sessions. Significant reduction in anxiety symptoms and functional impairment noted. Continued focus needed on challenging perfectionist thinking patterns and developing balanced thinking skills.

Session Focus Next Week: Behavioral experiments and activity scheduling

Next Appointment: [Date] for continued CBT and behavioral intervention planning.

SOAP Note: Bipolar Disorder Mood Episode Assessment

31-year-old male with established Bipolar I Disorder presents for follow-up during current manic episode. Reports elevated mood for past 10 days, describing feeling "on top of the world" and "unstoppable." Sleep decreased to 2-3 hours nightly without fatigue. Increased goal-directed activity including starting multiple business ventures and excessive spending ($5,000 on credit cards in past week). Speech described by family as "rapid and hard to follow." Reports racing thoughts and distractibility. Discontinued lithium 3 weeks ago stating "I don't need it anymore." No substance use reported. Family expresses concern about erratic behavior and poor judgment.

Patient appears well-groomed, hypervigilant, and energetic. Elevated mood with euphoric affect. Speech is pressured, loud, and difficult to interrupt. Flight of ideas evident with frequent topic changes. Psychomotor agitation - unable to sit still, pacing during interview. Demonstrates grandiose thinking, claims to have "revolutionary business ideas that will change the world." Insight poor regarding illness and need for treatment. Judgment significantly impaired. No evidence of psychotic features currently. Young Mania Rating Scale (YMRS): 28 (severe mania).

Bipolar I Disorder, Most Recent Episode Manic, Severe (F31.13). Patient experiencing acute manic episode with significant functional impairment and risk-taking behaviors. Medication non-compliance precipitated current episode. High risk for continued poor judgment, financial consequences, and relationship damage. No current psychotic features but risk for progression. Immediate intervention required to prevent further deterioration.

Risk Assessment: Moderate risk for impulsive behaviors, financial harm, and relationship consequences

Next Appointment: [Date] in 3 days for medication response evaluation and safety assessment.

SOAP Note: Couples Therapy Communication Session

Married couple (together 8 years, married 5 years) presents for session 4 of couples therapy. Wife (34) reports feeling "unheard and dismissed" when trying to discuss household responsibilities and parenting decisions. States husband "shuts down" during conflicts and "walks away mid-conversation." Husband (36) reports feeling "criticized constantly" and describes wife as "never satisfied with anything I do." Both agree arguments have increased in frequency (2-3 times weekly) since birth of second child 6 months ago. Sexual intimacy decreased significantly. Both express love for each other and motivation to improve relationship. No history of domestic violence or substance abuse.

Couple sits on opposite ends of couch, minimal eye contact initially. Wife appears anxious, speaks rapidly, and interrupts frequently. Husband appears withdrawn, crosses arms, and gives brief responses initially. During structured communication exercise, both demonstrate poor listening skills and defensive responses. Wife uses "you always/never" statements. Husband exhibits stonewalling behavior when overwhelmed. Both show improvement when guided through reflective listening techniques. Body language becomes more open during positive sharing exercise. Both demonstrate genuine care when discussing shared values and goals for family.

Relationship distress with maladaptive communication patterns (Z63.0). Couple demonstrates classic pursuer-distancer dynamic with escalating negative interaction cycles. Stressors include adjustment to second child, sleep deprivation, and role strain. Both partners show willingness to engage in therapy process and demonstrate underlying attachment bond. Communication skills deficits rather than fundamental relationship incompatibility. Good prognosis with continued therapy engagement.

Treatment Goals: Improve communication patterns, increase emotional intimacy, develop conflict resolution skills

Next Appointment: [Date] for continued communication skills development and homework review.

SOAP Note: ADHD Evaluation - Adult Assessment

28-year-old female self-referred for ADHD evaluation. Reports lifelong difficulties with attention, organization, and impulsivity that have worsened with increased work responsibilities. Current symptoms include difficulty sustaining attention during meetings, frequent procrastination on important tasks, losing important items (keys, phone, documents), and interrupting others in conversations. Work performance reviews cite "inconsistent attention to detail" and "difficulty meeting deadlines." Reports hyperfocus on interesting tasks while struggling with routine activities. Sleep pattern irregular due to "racing thoughts at bedtime." Tried multiple organizational systems without sustained success. Family history positive for ADHD (brother diagnosed in childhood). No current substance use.

Patient appears alert and cooperative but fidgets frequently throughout interview. Makes good eye contact but easily distracted by sounds outside office. Speech is spontaneous and somewhat tangential. Demonstrates difficulty staying on topic without redirection. Reports completing college and graduate degree but required significant accommodations and extended time. Currently employed as marketing coordinator but struggles with administrative tasks. Adult ADHD Self-Report Scale (ASRS): 24/24 (highly suggestive of ADHD). Conners Adult ADHD Rating Scale completed by patient and romantic partner both indicate significant symptoms.

Attention-Deficit/Hyperactivity Disorder, Combined Presentation (F90.2). Patient meets DSM-5 criteria with clear evidence of symptoms before age 12 (based on childhood report and school records reviewed). Current symptoms cause significant impairment in occupational and social functioning. Differential diagnoses of anxiety and depression were considered but symptoms are better explained by ADHD. No evidence of substance use disorder or other psychiatric conditions that would account for attention difficulties.

Medication Education: Discussed potential side effects, importance of regular meals, and avoiding late-day dosing

Next Appointment: [Date] for medication titration and symptom monitoring.

SOAP Note: Psychiatric Medication Management

43-year-old male with Major Depressive Disorder returns for medication management follow-up. Currently taking Sertraline 100mg daily for 8 weeks with partial response. Reports improved sleep and appetite but continues to experience low mood, anhedonia, and concentration difficulties. PHQ-9 score decreased from 18 to 12 but patient desires further improvement. No suicidal ideation currently. Reports mild sexual side effects (decreased libido) but tolerable. Compliance excellent with current regimen. Concurrent weekly psychotherapy ongoing with good engagement. No substance use. Supportive family relationships and stable employment.

Patient appears alert and cooperative with improved self-care compared to initial presentation. Mood remains somewhat depressed but less severe. Affect shows greater range than previous visits. Speech normal rate and volume. Thought process goal-directed and organized. Denies current suicidal ideation with good future orientation. Memory and concentration improved but still below baseline. Vital signs stable: BP 128/82, HR 72, Weight stable. No extrapyramidal symptoms or other medication side effects observed.

Major Depressive Disorder, moderate severity (F33.1) with partial response to current antidepressant therapy. Patient showing clinical improvement but has not achieved remission. Current symptoms continue to impact quality of life and functioning. Medication adjustment indicated to optimize treatment response. Good medication compliance and therapy engagement are positive prognostic factors.

Treatment Goal: Achieve PHQ-9 score <5 (remission) while maintaining tolerability

Next Appointment: [Date] for medication response assessment and possible further adjustments.