SOAP Note Example

Childhood Trauma

Client is healing from childhood trauma using IFS therapy.

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 his experiences of childhood neglect and its impact on his current relationships. He stated, "I feel like I can’t trust anyone." Client engaged in exploring his feelings and the connection to past events.

Objective:
Therapist conducted a 60-minute session at the office. Client seemed engaged and willing to participate in therapy. IFS therapy was utilized to assist the client in understanding and healing wounded parts.

Assessment:
Client is making progress in therapy through expressing his emotions and willingness to engage in IFS therapy. His acknowledgement of childhood experiences influencing present relationships is an indicator of his self-awareness.

Plan:
Client is assigned homework to journal about his parts and their protective roles. Next session is scheduled for next week to continue with IFS therapy and follow up on the homework assignment.

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 met with the therapist for a 60-minute session at the office. He talked about his experiences of neglect during childhood and how it affects his relationships today. He said, "I feel like I can’t trust anyone." We used IFS therapy to help him understand and heal his wounded parts. Client’s homework is to journal about his parts and their protective roles. He seemed engaged and willing to explore this therapeutic approach. We’ll follow up in our next session 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.

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