SOAP notes are commonly used in mental health documentation. This template adds mental health-specific fields including mood, affect, risk assessment, and psychiatric symptom tracking to the standard SOAP structure.
Part of our therapy notes templates collection.
Client Name: Date: Session Type: Duration: Subjective: Reported Symptoms: Mood (client-reported): Sleep/Appetite Changes: Stressors: Objective: Observed Affect: Behavior/Engagement: Mental Status Observations: Risk Assessment: Assessment: Clinical Impression: Progress Toward Goals: Diagnostic Considerations: Plan: Interventions for Next Session: Medication Considerations: Homework/Between-Session Tasks: Follow-Up Schedule:
Client: D.W.
Date: April 3, 2026
Subjective
Client reported persistent low mood and anhedonia over the past two weeks. Described difficulty sleeping (4-5 hours/night) and decreased appetite. Denied suicidal ideation. Identified work stress as primary trigger.
Objective
Affect flat with limited range. Speech normal rate and volume. Client appeared fatigued. Eye contact reduced. Cooperative and engaged despite low energy. No psychomotor agitation or retardation. Denied SI/HI/SH.
Assessment
Symptoms consistent with moderate depressive episode. PHQ-9 score: 14. Functional impairment increasing — client missed two days of work this week. Client demonstrates insight and treatment motivation.
Plan
Continue behavioral activation with focus on physical activity. Introduce activity scheduling. Assign mood tracking homework. Discuss medication evaluation referral at next session if symptoms persist. Next session in one week.
When documenting mental health sessions, pay attention to these clinical observations:
Mood — client's reported emotional state
Affect — observed emotional expression and range
Behavior — engagement level, psychomotor activity, cooperation
Appearance — grooming, hygiene, notable changes
Speech — rate, volume, coherence, latency
Thought process — organized, tangential, circumstantial
Cognition — orientation, concentration, memory
Outpatient mental health sessions
Psychiatric follow-up appointments
Behavioral health programs
Community mental health documentation
Telehealth mental health sessions
Substance use treatment sessions
Document mood and affect separately (client-reported vs observed)
Include risk assessment when clinically indicated
Use standardized measures (PHQ-9, GAD-7) when available
Name specific interventions used
Connect assessment to treatment goals
Write notes promptly after sessions
Not separating client-reported mood from observed affect
Missing risk assessment documentation
Using vague intervention descriptions
Not including standardized measure scores
Failing to document medication considerations
AI-assisted documentation can generate structured SOAP notes from brief session summaries.
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A mental health SOAP note uses the standard SOAP format (Subjective, Objective, Assessment, Plan) with additional focus on mood, affect, risk assessment, and psychiatric symptoms relevant to behavioral health documentation.
Mental health SOAP notes emphasize mood and affect observations, psychiatric symptoms, risk assessment, and therapeutic interventions rather than physical exam findings and lab results.
Yes, when clinically indicated. Documenting risk assessment — including suicidal ideation, self-harm, and safety concerns — is standard practice in mental health documentation.
Document specific therapeutic interventions used (e.g., cognitive restructuring, psychoeducation, exposure) rather than generic terms like 'supportive therapy.'
Generate structured therapy notes in minutes — no session recording required.