Build your note
1. Pick a format
2. Session details (optional)
3. SOAP sections
Subjective
What the client reported: concerns, feelings, and direct quotes (attributed, e.g. Client stated "...").
Phrase chips
Intervention verbs
Client response
Mood & affect
Presentation
Progress
Objective
What you observed: presentation, mood/affect, behavior, and measurable data.
Phrase chips
Intervention verbs
Client response
Mood & affect
Presentation
Progress
Assessment
Your clinical impression, interventions used, client response, progress toward goals, and risk.
Risk quick-select
Phrase chips
Intervention verbs
Client response
Mood & affect
Presentation
Progress
Plan
Next steps, homework, referrals, and the date/type of next contact.
Phrase chips
Intervention verbs
Client response
Mood & affect
Presentation
Progress