Mental Health SOAP Note Example

Fictional example for reference. This illustrates a progress-note narrative, not a complete clinical record.

S: Subjective

Client reports that she has not told her sister she attends therapy. She worries that disclosure would lead to repeated check-ins. She reports rehearsing possible conversations during several evenings and becoming distracted from tasks. She remains unsure whether she wants to disclose.

O: Objective / session work

The clinician observed clear speech, relevant responses and longer pauses when discussing disclosure. The clinician explored hoped-for and unwanted outcomes, helped identify a privacy boundary, and rehearsed a possible opening sentence. The client identified what she would keep private and said the exercise clarified that boundary. When asked, the client denied thoughts of harming herself or others.

A: Assessment

Anticipated family reactions appear to contribute to indecision and distraction from evening tasks. The client clarified one privacy boundary during the session and remains undecided about disclosure.

P: Plan

Client and clinician agreed that the client would make a private list of what she would and would not feel comfortable sharing. At the next appointment on October 15, 2026, revisit the decision and its effect on evening activities.

Reviewing the AI draft

The first AI-generated draft of this note recorded a conversation that had not happened. The clinician corrected it before saving.

Use the structure and level of detail as a reference. Write from the actual encounter and meet the documentation requirements that apply to your practice and payer.