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Counseling Session Summary Notes (Soap Notes)

This document provides guidelines for SOAP notes, which are used by counselors to document counseling sessions. SOAP notes include four sections: Subjective (how the client describes their issue), Objective (counselor's observations of the client), Assessment (counselor's analysis), and Plan (goals and strategy for future sessions). The guidelines explain what information should be included in each section, such as the client's presenting problems in Subjective, behavioral observations in Objective, conceptualization of themes and patterns in Assessment, and short and long-term goals as well as planned approach in Plan.

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Hijo del Duque
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218 views

Counseling Session Summary Notes (Soap Notes)

This document provides guidelines for SOAP notes, which are used by counselors to document counseling sessions. SOAP notes include four sections: Subjective (how the client describes their issue), Objective (counselor's observations of the client), Assessment (counselor's analysis), and Plan (goals and strategy for future sessions). The guidelines explain what information should be included in each section, such as the client's presenting problems in Subjective, behavioral observations in Objective, conceptualization of themes and patterns in Assessment, and short and long-term goals as well as planned approach in Plan.

Uploaded by

Hijo del Duque
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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COUNSELING SESSION SUMMARY NOTES (SOAP Notes)

Counselor: _______________________ Time: _____

Session Date: ________________

Client(s) Name: ___________________________________________________ Session #: ______ *********************************************************************** * Client Description:

Subjective Complaint:

Objective Findings:

Assessment of Progress:

Plans for Next Session:

Needs for Supervision:

GUIDE TO SOAP NOTES Client Description: Manner of dress, physical appearance, illnesses, disabilities, energy level, general self-presentation. (Only update after first session) Presenting problem(s) or issue(s) from the clients point of view. What the client says about causes, duration, and seriousness of issue(s). If the client has more than one concern, rank them based on clients perception of their importance. Counselors observation of the clients behavior during the session. Verbal and nonverbal, including eye contact, voice tone and volume, body posture. Especially note any changes and when they occur (such as a client who becomes restless in discussing a topic or whose face turns red under certain circumstances). Note discrepancies in behavior. Counselors view of the client, beyond what the client said or did. Continual evaluation of client in terms of emotions, cognitions, and behavior. Identification of themes and patterns in what client says and does. Use of developmental (Erikson, social learning theory) or mental health models (DSM-IV). Include your hypotheses, interpretations, and conceptualization of client. Plans for client, not for the counselor. Short and long-term goals. How you want to interact with client; what you may plan to respond to in next session with client (follow-up on family issues discussed). Do you plan to help client focus on thoughts, feelings, or behaviors? What particular strategy or theoretical approach might you use? What do you base your plan on? What reading or research do you need to do in preparation? Practice? What help do you need from your supervisor?

Subjective Complaint:

Objective Finding:

Assessment of Progress:

Plans for Next Session:

Plans for Counselor:

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