Sample SOAP Note

Diagnosis

F41.1 General Anxiety Disorder

Risk Assessment

Patient denies all areas of risk. No contrary clinical indications present.

Symptom Description and Subjective Report

The client is worried about how meeting up with a guy she used to work with will affect her current relationship. she feels like her best friend's boyfriend is a negative influence and is causing her stress. The client is struggling with setting boundaries with her friends, specifically her boyfriend's friends.

Objective Content

The client was talkative and nervous during the session. They had good eye contact and spoke quickly.

Interventions Used

Exploration of Emotions, Exploration of Relationship Patterns, and Supportive Reflection

Treatment Plan Progress

Objectives

1. RC will accept the client with unconditional positive regard in order to develop rapport.

   Progress: Progressing

2. RC will utilize behavioral rehearsal to prepare the client for facing the identified difficult social situations and brainstorm at least 3 approaches that the client will utilize.

   Progress: Progressing

3. RC will assist in identifying the thoughts, feelings, and actions that have characterized current low self-esteem. RC will teach client communication and social skills that will improve client’s ability to respond effectively in 4 of 6 situations. RC will assign weekly exercises to gradually help client utilize these skills.

   Progress: Progressing

4. Rehabilitation Counselor (RC) will furnish client with coping techniques on diminishing feelings of trauma; RC will educate client on the concept of “triggers;” RC will assist in development of a plan to incorporate coping skills and techniques into a weekly plan.

   Progress: Progressing

Additional Notes / Assessment

The session went well, with the client discussing her feelings about her best friend's boyfriend and how he has been a negative influence in her life. The client has made progress from the last session in terms of communicating her feelings and setting boundaries with her best friend. Overall, the session was helpful in exploring the client's relationship with her best friend and how to best deal with her best friend's boyfriend.

Plan

RC will continue to work with the client on setting boundaries and communicating her feelings. the therapist will also assign homework for the client to work on between sessions. The focus for the future will be on helping the client practice setting boundaries.