This page gives you a SOAP notes template for each kind of session a therapist writes up most: an individual adult session, a telehealth session, a couples session, a child or teen with a parent check-in, one member of a group, and a short follow-up. Each template has a one-line "What goes here" under every heading and prompts to write against, one field per line, so you can paste it straight into your notes and delete what you don't need.
These templates are for therapy and counseling notes. If you came for a medical SOAP note (vital signs, physical exam, review of systems), they leave those fields out on purpose; the section on medical templates below explains the difference. If you want to see finished notes first, our SOAP note therapy examples has four complete notes from invented sessions. This page is the template side: what to copy, how to adapt it, and the habits that turn a good template into cloned notes.
Which SOAP template to use
- Individual adult therapy:the standard 45 to 60 minute session in the office. Start here if you only want one.
- Telehealth session:any session by video or phone. It adds the lines about location, privacy, emergency details and the connection.
- Couples session:two partners, one session. Each partner's account is labeled, and the Objective section is about what happens between them.
- Child or teen with a parent check-in:a minor seen alone for most of the session, with a parent or guardian for part of it.
- Group member:one member's note from a group session, written for that member's record.
- Short follow-up:a brief session or routine check-in with a stable client, when what matters is what changed.
- Blank template:the four headings and the header lines, for when you already know what to write.
What every template on this page has in common
Three things are built into every template below, and they are worth keeping when you adapt them.
- Header lines first. Date, start and end time, format, who attended and the goals addressed are what a payer or reviewer checks before reading anything clinical. Psychotherapy codes are billed by time, and missing time was the most common problem in a nationwide federal audit of psychotherapy claims (more in the mistakes section).
- A "What goes here" line under each heading. It is a reminder for you, not part of the note. Delete it, and every prompt you didn't answer, before you sign.
- "What is different from the last note." A one-line field at the end of each template. If you can't fill it in, read the note again: either the session really was a repeat, which the note should say, or the note was copied.
Where do interventions go? These templates put them in Objective, beside the client's response, because both are things you could observe. Our examples article explains that choice and the alternatives; pick one place and keep it.
SOAP notes template 1: individual adult therapy
Use it for a routine individual session in the office. It is the base the other templates build on.
If you give the PHQ-9 or GAD-7, the PHQ-9 scoring tool and GAD-7 scoring tool add up the total; record it in Objective beside the last score.
SOAP notes template 2: telehealth session
Use it for any session by video or phone. Most of the additions are at the top: the facts you need if the call drops or you have to send help, and the facts a payer may ask about.
Two of these lines matter more than they look. The client's location matters because your license is generally tied to the state where the client is during the session, and you need it if you ever have to send emergency help. The audio-only reason matters because some payers set conditions for it: Medicare, for example, allows audio-only telehealth to a patient at home when the clinician can use video but the patient can't or doesn't consent to it (42 CFR 410.78(a)(3)). Our informed consent article covers what telehealth consent usually includes.
SOAP notes template 3: couples session
Use it when two partners attend together. The Subjective section labels each partner's account, and Objective records the pattern you saw between them, which is often the most useful clinical data in couples work.
Decide at intake whether the couple shares one record or each partner has their own, and file the note to match. That choice affects who can read the note and who must sign a release before you share it, so check your state's rules and your own policy.
Many couples therapists screen for intimate partner violence with each partner alone, because a partner may not be safe to answer in a joint session. If you do, decide in advance where that screen is recorded, especially when the couple shares a record.
SOAP notes template 4: child or teen with a parent check-in
Use it when a minor is seen alone for most of the session and a parent or guardian joins for part of it. Every report is labeled by who gave it, and the time split is recorded because it shows who the session was with.
There is no line for "what stayed private," on purpose. Depending on your state, a parent or guardian may have the right to read a minor's record, so the note itself can't be where you keep a teen's confidences. Agree at intake what you will share with parents (attendance and the plan, for example, with safety concerns always shared), write each note so it respects that agreement, and check your state's rules on minors' consent and records.
SOAP notes template 5: one group member
In group therapy, each member gets their own note in their own record. The group summary at the top can read the same in every member's note; everything under S, O, A and P must be about this member alone. Refer to other members without names or details that could identify them.
The group summary is the one place in these templates where shared text is expected. If a member's note is only the group summary and a line saying they attended, it says nothing about that member, which is the cloned-note problem in a different form.
SOAP notes template 6: short follow-up note
Use it for a brief session or a routine check-in with a stable client: a monthly maintenance session, for example, or a short session agreed in the treatment plan. Short doesn't mean empty. Each section still needs today's facts, and the note says why the session was brief.
Here is how the short template looks filled in, for an invented client, a 58-year-old retired bus driver we'll call Walt, in maintenance treatment for depression. Every client in this article is invented; any resemblance to a real person is a coincidence.
- Date of service: 10/22, 2:00 to 2:30 PM, by video; client at home in Ohio, alone
- Reason brief: monthly maintenance check-in, as set in the treatment plan
- Goal addressed: goal 3, prevent relapse (keep the PHQ-9 below 10)
Subjective: Reports a steady month. Started volunteering at a food bank two mornings a week, as planned last time. Sleep "about the same, seven hours." When asked about thoughts of suicide, said, "No. Not since the spring."
Objective: On time, dressed and shaved, affect brighter than last month; laughed twice. PHQ-9 6 (8 four weeks ago). Reviewed his relapse warning signs list; he added "skipping the morning walk."
Assessment: Depressive symptoms stable to improving: PHQ-9 down 2 points, and he kept the volunteering plan. Risk low and unchanged. Monthly sessions remain appropriate through the winter, when his symptoms returned last year.
Plan: Keep volunteering twice a week and the morning walk; call the office if two warning signs appear in one week. Next session 11/19, 2:00 PM, by video. Goal 3 continues.
About 130 words, and nothing in it could be pasted into next month's note.
Blank SOAP note template
The bare version, for clinicians who already know what each section needs. Keep the header lines even here.
Quick-fill phrases for each section
Sentence starters with blanks, to fill with today's facts. Use them to get moving, not as finished lines: a stem left half-filled, or the same stem with the same words every week, is how a template note starts to look cloned. For full word lists (affect words, intervention verbs, risk wording), keep our progress notes cheat sheet beside you.
Subjective
- Client reports [symptom] on [number] of the past 7 days, compared with [number] the week before.
- Client describes [event] as "[short quote]."
- Client reports doing [task] [number] times since last session; did not do [task] because "[reason]."
- [Parent / partner] reports [what they noticed]; client [agrees / disagrees / did not comment].
- When asked about thoughts of suicide or self-harm, client said, "[answer]."
- When asked about [area], client reported no change since [date].
Objective
- Arrived [on time / number minutes late]; [appearance in a few words].
- Affect [word], [fit / did not fit] the stated mood of "[client's word]."
- [Measure] total [score] ([previous score] on [date]).
- Practiced [technique] for [minutes]; [rating] before and [rating] after.
- Needed [number] prompts to [use the skill].
- Joined by [video / phone] from [type of place]; [alone / others present].
Assessment
- Progress toward goal [number] is [better / the same / worse], as shown by [evidence from S or O].
- [Symptom] appears to be kept going by [pattern], seen today in [example].
- Response to [intervention] suggests [reading]; [continue / adjust] next session.
- Risk is [unchanged / higher / lower] than [baseline / last session] because [reasons]; protective factors include [factors].
- Continued [frequency] therapy is needed to address [symptom], which limits [work, school, sleep, relationships].
Plan
- Client will [task] [number] times before [date] and record [what to track].
- Therapist will [next step] at the next session.
- With [client's / parent's] signed release, therapist will contact [provider] about [topic] by [date].
- If [warning sign or score], [what happens].
- Next session [date], [format]; goal [number] [continues / revised / met].
How to adapt a SOAP template to your practice
A template you copy from the internet, this one included, is a starting point. Make it yours before you use it with clients. The professional codes set the bar it has to meet: the NASW Code of Ethics asks social workers to keep documentation that "is accurate and reflects the services provided" and includes "only information that is directly relevant to the delivery of services" (NASW Code of Ethics, 3.04), and the APA's guidelines ask psychologists to make "legible and accurate entries" in client records "as soon as is practicable after a service is rendered" (APA Record Keeping Guidelines).
- Start with the rules you answer to. Your payer contracts, your state board's record rules, and your agency or group practice policy come first. If they require a line these templates don't have (a supervisor's cosignature, a level-of-care line, an authorization number), add it.
- Delete what you don't do. Remove any line you won't fill in for that kind of session. An empty "Vital signs" or "Physical exam" line in a therapy note invites the question of why it's there.
- Prefill only what never changes. Your name, credentials and office address are safe to prefill. Mental status findings, risk answers, interventions and progress are not: if the template opens with "Affect: euthymic" already typed, sooner or later a note will say it on a day it wasn't true.
- Add the measures you actually track. If you use a diary card, distress ratings during exposure or a particular outcome measure every session, give it a named line in Objective.
- Number your goals. Write the treatment plan goals the same way every time (goal 1, goal 2) so each note's progress line points to one.
- Make one version per kind of session, not per client. Six templates you know well are easier to keep current than forty client-specific copies.
- Test it on three real sessions. After a week, cut every prompt you skipped all three times, and add any line you kept writing in by hand.
- Keep private reflections out. Your own reactions and notes for supervision don't belong in a progress note template. Under HIPAA, "psychotherapy notes" are a separate category only when kept apart from the rest of the record (45 CFR 164.501).
Mistakes templates cause: copy-forward and cloned notes
Templates save time because they repeat structure. The trouble starts when they repeat content. CMS describes cloning as "copying and pasting previously recorded information from a prior note into a new note," and its fact sheet on electronic records is direct about the standard: "The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable" (CMS, Electronic Health Records Provider fact sheet).
The HHS Office of Inspector General has looked at the same problem from the auditor's side. In a 2014 report, it found that not all Medicare contractors could tell whether a provider "had copied language or overdocumented in a medical record," and it recommended that CMS give contractors guidance on fraud in electronic records and direct them to use providers' audit logs, which record who created or changed an entry and when (OIG, OEI-01-11-00571). In 2023, its nationwide audit of Medicare psychotherapy payments found that providers did not meet Medicare requirements for 128 of 216 sampled enrollee days, for example because psychotherapy time was not documented, and fell short of Medicare guidance on 54, for example because signatures were missing. It estimated that 580 million of the roughly 1 billion dollars Medicare paid for psychotherapy in the first year of the COVID-19 public health emergency went to services that did not comply (OIG, A-09-21-03021).
Even if you never bill Medicare, the same habits make a record harder to defend to a private payer, a licensing board or a court. Here is how templates lead to them:
- Copy-forward.Starting today's note from last week's and editing a few words. Old facts survive: a risk statement from a month ago, homework the client finished, a symptom that has resolved. Start from the blank template each time and read last week's Plan, not its text.
- The same note for every client.A paragraph that reads the same across your caseload ("Client engaged well and processed feelings") shows nothing about this client. The CMS standard above asks for the differences.
- Prefilled normal findings.A mental status section that opens already filled in, or a checklist of interventions with every box ticked, records what the template says rather than what happened.
- A safety line on autopilot."Denies SI/HI" in every note, whether or not you asked. Write what you asked and what the client said, in today's words.
- Prompts left in."What goes here" lines, empty fields and "N/A" on every line make a note look unread. Delete them before you sign.
- Missing time, treatment plan or signature.The most common problem in the 2023 audit was undocumented psychotherapy time (60 of the 216 sampled days), followed by incomplete or missing treatment plans (43); signatures were missing on 31. Every template above has start and end time at the top, goal lines tied to the treatment plan and a signature line at the bottom; keep all three.
- A group summary instead of a member's note.Shared group text is fine; a note that is only shared text is not.
- A template that outlives the treatment plan.When goals change, update the goal lines. Notes that track goals the client met months ago read as copied.
The "What is different from the last note" line in every template is the quickest check against all of these. If the honest answer is "nothing," say why the session was still needed.
If you came for a medical SOAP note template
SOAP began in medicine, and medical templates look different because the visit is different:
- Medical Subjective:chief complaint, history of present illness, review of systems, medications and allergies. Therapy Subjective: the client's account of the week, mood in their words, homework and what they said when asked about safety.
- Medical Objective:vital signs, physical exam, labs and imaging. Therapy Objective: appearance, behavior, speech, affect, measure scores, and what you did in the session with the client's response.
- Medical Assessment:diagnosis and differential diagnoses. Therapy Assessment: progress toward treatment goals, what keeps the problem going, risk and why care is still needed.
- Medical Plan:orders, prescriptions, procedures and follow-up. Therapy Plan: homework, next session focus, coordination of care and the next date.
If you prescribe, your notes need the medication and side-effect fields these templates leave out. Nurses, physical therapists and physician assistants should use a template from their own field.
SOAP, DAP or BIRP: a quick comparison
- SOAP splits the client's account (Subjective) from your observations (Objective). Use it when the source of information matters, as with couples, families, minors and risk, or when you work alongside medical providers.
- DAP puts the client's account and your observations together in Data, for a shorter note. See our DAP notes examples and template.
- BIRP gives your interventions and the client's response their own sections. See our BIRP note examples, which show one session written in all three formats.
- GIRP organizes each note around a treatment plan goal.
Whichever you choose, use it consistently for each client. Reviewers care about what the note contains more than which letters head the sections.
What to check with a clinician or supervisor before you use these templates
These templates are a general starting point and haven't been fitted to any state, payer or setting. Before you adopt one, check:
- Risk lines against your setting's risk assessment and documentation policy.
- Minors: who can consent to treatment, what parents or guardians can read under your state's law, and what you told the family at intake.
- Couples: one shared record or two, how you screen for intimate partner violence, and whose authorization a release needs.
- Groups: your payer's rules for group notes and how your practice refers to other members.
- Telehealth: licensure in the client's state, your payers' telehealth and audio-only rules, and your consent form.
- Billing lines: codes, time rules and modifiers, from your payer contracts and current coding guidance.
- Supervision: if you are pre-licensed, the cosignature and review steps your supervisor and board require.
How this works in TranqBay
TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions and session notes in one place. Here is where a SOAP note fits.
- Choose SOAP for the session's note. Session notes can be written in SOAP, DAP, BIRP or GIRP format, or as a blank note in your own words. Because a blank note is your own text, you can paste in any template from this page and keep your layout.
- Structured formats such as SOAP are part of the advanced note templates, which some plans include.
- Video sessions are HIPAA-ready, and TranqBay signs a Business Associate Agreement with you, which matters for anything you store, notes included.
- Forms before the session. TranqBay's form library has ready-made templates you can send a client for a session, including intake forms (general, couples and child), consent to treat, telehealth consent, release of information, the PHQ-9 and the GAD-7. The client fills them in online, and the answers wait with the session. TranqBay doesn't score them: add up the total and write it in Objective beside the last score.
If you want to see where a note sits before you set anything up, practice.tranqbay.health shows a session page with its note, next to the booking and the video session.
Frequently asked questions about SOAP notes templates
What should a mental health SOAP notes template include?
Header lines (client, date, start and end time, format, who attended, goals addressed), then the four sections: Subjective for the client's account, Objective for what you observed and did, Assessment for your reading and progress, and Plan for next steps. For telehealth, add the client's location, privacy and emergency details. End with your signature, credentials and the date signed.
Can I use a medical SOAP note template for therapy?
You can, but you'll delete most of it. Medical templates ask for vital signs, a physical exam and a review of systems, and most have no clear place for the therapy you did in the session. A therapy template replaces those with affect, behavior, measure scores, interventions and the client's response.
Is it OK to copy and paste from last session's SOAP note?
Copying the structure is fine; copying the content is where the risk is. CMS says the record must show "the differences and the needs of the patient for each visit." If you carry anything forward, such as a goal or a diagnosis, check it against today's session before you sign.
Should my SOAP template prefill normal findings?
No. Prefill only what never changes, such as your name and credentials. Prefilled mental status findings or risk answers end up in notes on days they weren't true.
Do I need a separate SOAP template for telehealth?
It helps. A telehealth note needs facts an office note doesn't: the client's location, whether they were alone, the emergency address and contact, the format (video or audio only, and why), and any interruptions. A separate template keeps those from being forgotten.
Does each partner need their own note in couples therapy?
It depends on how you keep the record. Some therapists keep one shared record for the couple; others keep a record for each partner and file the session note in one or both. Decide at intake, tell the couple, and check your state's rules on who can read the note and who must agree to a release.
Can one SOAP note cover a whole group?
No. Each member needs a note in their own record. The topic and group interventions can read the same in every note, but Subjective, the member's response, Assessment and Plan must be about that member.
Can I keep a SOAP template in Word or Google Docs?
Keeping the blank template there is fine: paste one from this page and save it as your own. Notes with client information belong only in a system covered by a Business Associate Agreement with you. Google Workspace can be, once an administrator accepts Google's BAA; our Gmail and HIPAA guide explains how that works.
How short can a SOAP note be?
As short as the session allows, as long as each section has today's facts. The short follow-up example above is about 130 words. A note that is short because it was copied is a different problem from a note that is short because little changed.
Do SOAP notes need start and stop times?
For psychotherapy billed by time, yes: missing time was the most common problem the OIG found in its 2023 psychotherapy audit. Even for private-pay clients, the times show how long you met and support the service you recorded.
Start with one template this week
Pick the template for the session you write up most, adapt it with the steps above, and use it for a week. Then add the next one. Before each note, read last week's Plan, and before you sign, fill in "What is different from the last note."
If you'd rather write notes in the same place you book and see clients, see how TranqBay works for private practice: you can look at a practice website template and the booking page your clients would use, then the session page where the note goes. If you're deciding whether to join, this page explains how joining TranqBay works.
Sources
CMS 1HHS 2Regulations 2Associations 2
Centers for Medicare & Medicaid Services1
U.S. Department of Health and Human Services2
- 2HHS Office of Inspector General, CMS and Its Contractors Have Adopted Few Program Integrity Practices To Address Vulnerabilities in EHRs, OEI-01-11-00571 (January 2014)oig.hhs.govhttps://oig.hhs.gov/reports/all/2014/cms-and-its-contractors-have-adopted-few-program-integrity-practices-to-address-vulnerabilities-in-ehrs/
- 3HHS Office of Inspector General, Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, A-09-21-03021 (May 2023)oig.hhs.govhttps://oig.hhs.gov/reports/all/2023/medicare-improperly-paid-providers-for-some-psychotherapy-services-including-those-provided-via-telehealth-during-the-first-year-of-the-covid-19-public-health-emergency/
Laws and regulations2
- 442 CFR 410.78: Medicare telehealth services, including audio-only conditions (eCFR)ecfr.govhttps://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-B/section-410.78
- 545 CFR 164.501: definition of psychotherapy notes (eCFR)ecfr.govhttps://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.501
Professional associations2
- 6National Association of Social Workers, Code of Ethics, standard 3.04 Client Recordssocialworkers.orghttps://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English/Social-Workers-Ethical-Responsibilities-in-Practice-Settings
- 7American Psychological Association, Record Keeping Guidelinesapa.orghttps://www.apa.org/practice/guidelines/record-keeping