Counseling session summary notes (soap notes)

COUNSELING SESSION SUMMARY NOTES (SOAP Notes) 1 2 1 Counselor: _______________________ Session Date: ________________ Time: _____ Client(s) Name: ___________________________________________________ Session #: ______ ************************************************************************ 2 Client Description: 3 Subjective Complaint: 4 Objective Findings: 5 Assessment of Progress: 6 Plans for Next Session: 7 Needs for Supervision: 3 GUIDE TO SOAP NOTES Client Description: Manner of dress, physical appearance, illnesses, disabilities, energy level, general self-presentation. (Only update after first session) Subjective Complaint: Presenting problem(s) or issue(s) from the client’s 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 client’s perception of their importance. Objective Finding: Counselor’s observation of the client’s 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. Assessment of Progress: Counselor’s 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 Next Session: 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? Plans for Counselor: What reading or research do you need to do in preparation? Practice? What help do you need from your supervisor?