SOAP Note Example

Body Image Issues

Client is addressing body image issues using DBT and mindfulness.

Generated SOAP Note:

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Subjective:
Client discussed her struggles with body image and self-acceptance, stating, "I hate how I look." She communicated engagement with the material by asking questions about the techniques introduced in session.

Objective:
The 45-minute session focused on the use of DBT to aid in emotional regulation and to introduce mindfulness practices.

Assessment:
Client was receptive to DBT interventions and the introduction of mindfulness practices to address her self-acceptance issues.

Plan:
Client’s homework is to practice body neutrality exercises and maintain a daily gratitude journal. The next session is scheduled for two weeks from today.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over.

Client had a 45-minute session today discussing her struggles with body image and self-acceptance. She said, "I hate how I look." We used DBT to address her emotional regulation and introduce mindfulness practices. Client’s homework is to practice body neutrality exercises and keep a daily gratitude journal. She was engaged and asked questions about the techniques. Our next session is scheduled for two weeks from today.

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More About SOAP Notes:

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