COUNSELOR’S TOOLKIT – SOAP Note Template

S — Subjective
Client’s self-reported symptoms, concerns, mood, stressors, insight, cravings, etc.
Template:
● Client reports:
● Client’s mood:
● Client identifies triggers/stressors:
● Client states progress/challenges:

O — Objective
Clinician’s observations; measurable, factual, non-interpretive.
Template:
● Appearance/behavior:
● Affect:
● Participation:
● UA results (if applicable):
● Mental status cues:
● Skills demonstrated in session:

A — Assessment
Clinician’s interpretation of subjective + objective data; clinical meaning.
Template:
● Clinical impression:
● Progress toward goals:
● Risk level (if relevant):
● Response to interventions:

P — Plan
Next steps, interventions, goals, homework, referrals.
Template:
● Continue with:
● Homework assigned:
● Next session focus:
● Referrals/coordination:
● Safety reminders (if applicable):

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SOAP Note — Completed Example (SUD / IOP)

S:
Client reports increased motivation this week and states, “I’m starting to feel more in control of my cravings.” Reports one trigger on Saturday due to family conflict but used grounding techniques to avoid use. Mood is “okay but tired.”

O:
Client arrived on time, engaged, maintained eye contact, and participated actively in group discussion. Affect congruent with mood; no signs of intoxication. UA from 1/5/25 negative for all substances. Client appeared slightly fatigued but attentive.

A:
Client demonstrates improving insight into relapse triggers and is effectively using coping skills. Risk remains low. Client is progressing toward treatment goals related to emotion regulation and relapse prevention.

P:
Client will continue practicing grounding skills daily. Therapist will introduce cognitive restructuring next session. Client asked to complete a trigger log before next visit. No safety concerns reported; follow-up scheduled for Tuesday.

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COUNSELOR’S TOOLKIT – DAP Note Template

D — Data
Combination of “Subjective + Objective” information (client report + clinician observations).
Template:
● Client stated/reported:
● Symptoms/mood:
● Observations/behaviors:
● Group participation:
● Relevant clinical data (UA results, attendance, assignments):

A — Assessment
Clinician’s interpretation, clinical significance, movement toward goals.
Template:
● Clinical impression:
● Progress/challenges:
● Risk level:
● Response to intervention:

P — Plan
Treatment plan actions, homework, follow-up, referrals.
Template:
● Interventions used:
● Homework/skill practice assigned:
● Next session focus:
● Referrals/coordination:
● Safety notes:

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DAP Note — Completed Example (SUD Step-Down Group)

D:
Client reports feeling “stressed but staying sober.” Identified work-related anxiety as the main trigger this week. Client shared that they attended two support meetings and completed the assigned coping-skills worksheet. Observed to be attentive, cooperative, and supportive toward peers. No signs of intoxication; UA from 1/6/25 negative.

A:
Client is maintaining abstinence and demonstrating increased ability to identify triggers and apply coping strategies. Anxiety remains moderate but manageable. Progress is steady. Risk rated low; client remains appropriate for step-down level of care.

P:
Client will continue attending at least two support meetings weekly. Therapist assigned grounding routine practice twice daily. Next session will focus on cognitive coping skills for anxiety. No safety concerns reported.