SOAP Note Example: Building Self-Confidence

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 attended a 60-minute session focused on building self-confidence. He reported feeling inadequate in social situations and stated "I feel so insecure." Therapy utilized CBT techniques to address negative self-beliefs and included role-playing to improve social interactions.

Objective:
The client presented as engaged and participated actively in the CBT exercises and role-playing. No alterations to client's mental status were observed during the session.

Assessment:
Client appears to be making positive strides in challenging negative self-beliefs and is optimistic about the exercises introduced. Progress in building self-confidence through CBT and role-playing was noted.

Plan:
Client's homework is to practice positive affirmations daily. The next session will occur next week to continue working on self-confidence and assess the efficacy of the interventions.

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.

Today’s 60-minute session with the client focused on building self-confidence. He mentioned feeling inadequate in social situations. He said, "I feel so insecure." We used CBT to challenge negative self-beliefs and role-playing to practice social interactions. Client’s homework is to practice positive affirmations daily. He seemed optimistic about the exercises. We’ll meet again next week.

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More About SOAP Notes:

From even more examples, to an overview of the format in general, to templates, to a cheat sheet, here's everything you need to know about SOAP notes.