2026 SOAP note examples for therapists

[Patient name] reports a difficult week with three panic-like episodes triggered by upcoming work deadlines. Reports continuing the daily thought record but notes it felt 'forced' on two evenings. Sleep down to 5 hrs avg this week; pattern of 4am wake-ups returned. Denies SI/HI.

Patient appeared on time via secure telehealth from [Location]. Affect anxious but engaged. GAD-7 administered this session: 13 (last session 11; baseline 18). PHQ-9: 8. Coordinated thinking; no thought disorder. Identified two cognitive distortions during in-session review: catastrophizing about a deliverable, mind-reading about a manager's tone.

Generalized Anxiety Disorder (F41.1), moderate severity, partial response to CBT. Symptom recurrence appears tied to environmental stressor (project deadline) rather than treatment plateau. Thought record practice has slipped under stress — classic relapse vulnerability. Risk: low.

Continue weekly CBT. This week's intervention: scheduled worry time (15 min, 7pm daily) plus behavioral experiment around the 'manager is angry' belief. Reissued the 3-column thought record with the addition of evidence-for/evidence-against. Next session [Date]. Coordinated with prescriber [Provider] re: PRN propranolol availability.

[Patient name] reports two crisis-level urges this week: one urge to self-harm (Tuesday, did not act) and one impulsive substance use urge (Friday, did not act). Reports using TIPP for the first urge and contacting a skills coach for the second. Diary card complete: emotions ranged 30-80; effective skills use averaged 4/7 days.

Patient on time, alert, no evidence of intoxication. Mood: 'tired but okay.' Diary card reviewed in detail — accurate self-monitoring evident. Walked through the chain analysis of Tuesday's self-harm urge collaboratively.

Borderline Personality Disorder (F60.3) with co-occurring features of substance use risk. Significant progress: two high-risk urges did not result in target behavior. Emotion regulation module mostly internalized; distress tolerance still emerging.

Continue weekly individual DBT + skills group. Homework: TIP skill (cold water, paced breathing, paired muscle relaxation, intense exercise) practiced once nightly regardless of urge presence. Chain analysis of Friday's substance urge to be completed before next session. Skills coach calls remain available 24/7. Next session [Date].

[Patient name] reports one nightmare in the past week (down from 4 last week), increased calm at work, and decreased startle response to elevator doors closing. Reports the negative cognition 'I'm in danger' feels 'further away' than it did at last session. Sleep improved to 7 hrs avg.

Patient settled quickly into the reprocessing chair. Bilateral stimulation: tactile tappers, set 1-1. Target memory from prior session re-accessed: motor vehicle accident, [Date], intersection at [Location]. SUDS at start: 4 (last session: 7). VOC for positive cognition 'I'm safe now': 5 (target ≥6).

Post-traumatic Stress Disorder (F43.10), chronic, in active treatment. Phase 4 reprocessing progressing; target memory desensitization on schedule. Adaptive resolution emerging — the positive cognition is gaining credibility. No dissociation observed during the set.

Continue Phase 4 reprocessing of the MVA target. Plan: complete this target next session, expecting SUDS to reach 0-1 and VOC to reach 7. Then move to Phase 5 (installation) and Phase 6 (body scan). Self-soothe protocol homework: container + safe place visualization nightly. Next session [Date].

[Patient name] reports a productive week and a clear shift: the 'inner critic' part (manager) has 'taken a step back' since last session's unburdening work. A previously-blended exile (described as 'the small one who froze') has become noticeable but less terrifying. Reports two evenings of unprompted self-compassion — 'I caught myself being kind to me.'

Patient appeared regulated and curious throughout. Direct access used twice; in-sight access used for the rest. The protective manager checked in but stepped back when invited. Self-energy access score: 7/10 (subjective). No dissociation. Affect stable.

Complex trauma adjustment, IFS conceptualization. Significant shift: the manager part appears more willing to relax its protective role. The exile becoming accessible (not yet retrieved/unburdened) is a meaningful next step — and a vulnerable one. Patient's Self capacity to lead is increasing.

Continue weekly IFS. Next session: hope to invite the exile to share its burden(s), with the manager's permission. Homework: journaling from Self when parts get loud, not journaling AS the parts. Self-energy practice (5-min check-in twice daily). Next session [Date].