Mental Health SOAP Note Examples for Common Diagnoses (with Templates)
Outline
Looking up a mental health SOAP note example by diagnosis is more useful than reading another generic SOAP template. The structural format is fixed (Subjective, Objective, Assessment, Plan), but how each section reads for an F41.1 anxiety client is genuinely different from how it reads for an F60.3 borderline client, an F33.1 depression client, or an F43.10 trauma client. The five worked notes below show the variation directly.
This guide covers generalized anxiety, recurrent major depressive disorder, post-traumatic stress disorder, bipolar II disorder, and borderline personality disorder. Each note carries the active ICD-10 code, the diagnostic-criteria reasoning, the modality-specific intervention, and the clinical decision logic that holds up under utilization review and licensing-board scrutiny. For the SOAP format reference (template + section-by-section reasoning), see the SOAP notes for therapists guide; this page focuses on the completed examples themselves.
Educational reference for licensed US therapists, psychologists, counselors, and clinical social workers. Documentation requirements vary by state licensing board, payer, and setting; check your local rules and clinic policy. The examples below align with American Psychological Association (APA) practice guidelines and with documentation patterns accepted in US Medicare and commercial payer audits.
Four elements every defensible note carries
Before the worked examples, four structural patterns are worth flagging. They show up in all five notes below regardless of diagnosis, and they are the patterns most often cited when a chart holds up under audit.
- Subjective in the client’s voice: direct quotes for symptom self-report, current functioning, and any safety-relevant statements. Quoted speech is much harder to argue with under board review than paraphrased self-report.
- Objective with the mental status exam populated: affect, mood, thought process, thought content, perception, cognition, and the safety domains (SI/HI, AVH). Brief MSE in routine notes; full MSE at intake and after clinically significant change.
- Assessment that ties symptoms to the active ICD-10 code: diagnostic-criteria evidence from this session, severity, and trajectory. The Assessment section is what a payer auditor reads first; it must do interpretive work, not restate the data.
- Plan with named interventions: modality-specific technique used in session, between-session task, focus for next session, and any treatment-plan adjustment. “Continue therapy” is not a plan; “continue cognitive restructuring on workplace-trigger thoughts; assigned thought record” is.
SOAP example 1: generalized anxiety disorder (F41.1)
Session context: Established client, F41.1 generalized anxiety disorder, session 8 of CBT, addressing return-to-work anxiety.
S: Client reports anxiety has been “manageable but still present this week.” Rates current GAD-7 as 11 (down from 14 four weeks ago). Returned to work for two half-days successfully; describes one panic episode on Tuesday lasting “about ten minutes” that resolved using breathing skill rehearsed in session. States, “I caught it earlier this time.” Sleep improved (6.5 hours per night, up from 5). Denies suicidal ideation.
O: Well-groomed, on time, cooperative throughout. Speech normal rate and rhythm. Mood reported as “cautiously hopeful”; affect congruent, full range, brightened during workplace discussion. Thought process linear and goal-directed. No SI/HI; denies AVH. A&O x4. Insight intact, judgment unimpaired.
A: Client demonstrating sustained skill generalization from in-session cognitive restructuring to workplace context. Reduced GAD-7 score, shorter panic-episode duration, and improved sleep are consistent with treatment-plan goal of return-to-work readiness. F41.1 active diagnosis; severity moderate, trending toward mild. Diagnostic criteria continue to be met (excessive worry, restlessness, sleep disturbance), but symptom intensity has reduced meaningfully.
P: Continued cognitive restructuring focused on workplace-trigger thoughts. Assigned thought record specific to first hour of work day. Continue paced-breathing rehearsal between sessions. Next session 7 days; will reassess GAD-7 and consider session-frequency taper if score stays below 10 for two consecutive weeks.
SOAP example 2: recurrent major depressive disorder (F33.1)
Session context: Established client, F33.1 major depressive disorder recurrent moderate, session 16 of integrated CBT and behavioral activation.
S: Client reports mood “still low but lighter than last month.” PHQ-9 administered today: 11 (down from 14 four weeks ago). Completed behavioral activation log for 6 of 7 days (improvement from 4 of 7 prior week). Reports increased contact with one supportive friend. Continues to describe difficulty initiating valued activities in the morning; afternoons are “more functional.” Denies SI; states, “I’m not where I want to be but I’m not where I was.”
O: Casually dressed, on time, mildly slow speech rate but normal rhythm. Mood reported as “tired but lighter”; affect congruent, restricted range with brightening during behavioral activation review. Thought process linear, mildly slowed. No SI/HI; denies AVH. A&O x4. Insight intact, judgment unimpaired. Psychomotor activity within normal limits.
A: Sustained behavioral activation engagement and reduced PHQ-9 score consistent with treatment-plan goal #2 (PHQ-9 below 10 sustained four consecutive weeks). F33.1 active diagnosis; severity moderate, trending toward mild. Diagnostic criteria continue to be met (low mood, anhedonia, fatigue, concentration difficulty), with anhedonia showing measurable improvement in the morning-versus-afternoon pattern.
P: Continue behavioral activation log; expand to include one valued-action item per day per ACT-informed adaptation. Cognitive restructuring next session on remaining maladaptive thought (“I’m wasting everyone’s time”). Next session 7 days. Anticipate PHQ-9 goal achievement within 3-4 sessions; will open transition-to-maintenance goal at that point.
SOAP example 3: post-traumatic stress disorder (F43.10)
Session context: Established client, F43.10 PTSD unspecified, session 11 of phase-based trauma treatment, currently in skill-building phase.
S: Client reports “fewer flashbacks this week, three instead of five or six.” Two flashbacks were brief (under one minute) and resolved with grounding skill #2; one was longer and required calling a partner. Sleep continues fragmented (4-5 hours, multiple awakenings). Reports successful workplace performance despite symptom load. Denies SI. States, “I feel like I’m fighting it less.”
O: Well-groomed, slightly late (apologetic about traffic), cooperative throughout. Speech normal rate and rhythm; mild latency before responses on more emotionally loaded topics. Mood reported as “tired but okay”; affect congruent, restricted in range during trauma-related content, broader during workplace discussion. Thought process linear. No SI/HI; denies AVH. A&O x4. Insight intact; judgment intact.
A: Reduced flashback frequency and improved skill deployment consistent with treatment-plan goal #1 (develop and rehearse three grounding skills for use during dissociative episodes; flashback-frequency reduction is a secondary outcome of skill mastery). F43.10 active; severity moderate. Diagnostic criteria continue to be met (re-experiencing, avoidance, hyperarousal, sleep disturbance). Client remains in skill-building phase per phase-based treatment plan; not yet appropriate for active processing.
P: Introduce and rehearse grounding skill #3 (paced breathing) next session. Continue weekly sleep log. Provide written summary of three skills for between-session use. Next session 7 days. Goal #1 anticipated achievement within 4 sessions; processing-phase transition planning will begin once skill #3 is reliably deployed independently.
SOAP example 4: bipolar II disorder (F31.81)
Session context: Established client, F31.81 bipolar II disorder, session 22, currently in euthymic phase. Co-managed with prescribing psychiatrist.
S: Client reports stable mood for the third consecutive week. Sleep regular (7.5-8 hours). Continues prescribed medication regimen with no missed doses; reports no current side effects. Mood-tracking log shows euthymic range throughout the week. Denies SI; denies hypomanic symptoms (no decreased need for sleep, no goal-directed activity surge, no pressured speech reported). Returned to part-time consulting work two weeks ago and reports it as “manageable.”
O: Well-groomed, on time, cooperative. Speech normal rate, rhythm, and volume. Mood reported as “stable, the boring kind of stable I’m starting to like”; affect congruent, full range. Thought process linear and goal-directed. No SI/HI; denies AVH. A&O x4. Insight intact; judgment intact. No psychomotor agitation or retardation.
A: Sustained euthymic presentation consistent with treatment-plan goal #1 (mood stability with no hypomanic or depressive episodes for 12 consecutive weeks). F31.81 active; currently in remission of episodes. Diagnostic criteria for active episode not currently met. Coordinated care with prescribing psychiatrist remains stable; medication regimen continues without adjustment.
P: Continue weekly sessions for early episode-detection support per phase-based treatment plan; transition to biweekly sessions planned at 12-week sustained euthymic threshold (currently 9 weeks). Continue mood-tracking log. Schedule joint coordination call with prescribing psychiatrist within 4 weeks. Next session 7 days.
SOAP example 5: borderline personality disorder (F60.3)
Session context: Established client, F60.3 borderline personality disorder, session 18 of standard DBT individual therapy, currently in stage 2.
S: Client reports diary card completed for all 7 days this week (improvement from 5 of 7 prior week). Two crisis-survival skill deployments noted on diary card: TIPP used Saturday during a relationship conflict, and self-soothe used Tuesday during work stress. Reports one urge to self-injure on Saturday rated 7/10 that did not result in self-injury. Reports skill-coaching call usage was effective. Denies current SI.
O: Casually dressed, on time, cooperative. Speech normal rate; intermittent emotional intensity around relationship content. Mood reported as “frustrated but okay”; affect congruent, full range, labile within session (tearful at one point during relationship discussion, brightened during diary card review). Thought process linear, mildly tangential during emotionally loaded content with brief redirection. No current SI; denies HI; denies AVH. A&O x4. Insight intact regarding skills application; judgment intact regarding safety.
A: Improved diary card completion and effective in-vivo skill deployment consistent with treatment-plan goal #2 (replace self-injury with crisis-survival skills 100% of the time). F60.3 active; severity moderate. Stage 2 DBT continues to be appropriate; no indication for stage transition this session. Diagnostic criteria continue to be met (emotion dysregulation, interpersonal sensitivity, identity uncertainty), with emotion dysregulation showing measurable skill-mediated reduction.
P: Continue diary card. Next session: chain analysis on Saturday self-injury urge to identify the prompting events and skill that interrupted the chain. Continue between-session skill-coaching call availability. Next session 7 days.
Copy-ready SOAP template for therapy progress notes
The five examples above are written for adaptation, not direct copy-paste. The blank template below carries the structure each example fills in.
Client: [Initials or ID] — Date: [YYYY-MM-DD] — Session: [Modality / length] Diagnosis (ICD-10): [Active code, e.g., F41.1, F33.1]
S — Subjective [Client’s self-report in their own words. Use direct quotes for symptoms, current functioning, and any safety-relevant statements. Include scores on standardized measures (GAD-7, PHQ-9, PCL-5) when administered.]
O — Objective [Brief MSE: appearance, behavior, speech, mood (quoted from S), affect, thought process, thought content, perception, cognition, insight, judgment, SI/HI status. Include observable in-session behavior tied to the modality.]
A — Assessment [Active ICD-10 code, diagnostic-criteria evidence from this session, severity, trajectory, treatment-plan goal status. Interpretive work, not data restatement.]
P — Plan [Specific intervention used in session, between-session task, focus for next session, any treatment-plan adjustment, next session date.]
For the full SOAP-format reference (section-by-section reasoning, defensibility checklist, format selection rules), see the SOAP notes for therapists guide. For format-comparison reasoning across SOAP, DAP, BIRP, and GIRP, see the progress note formats comparison.
Three documentation patterns shared across the examples
- The Assessment section does the interpretive work. Across all five examples, Assessment names the active ICD-10 code, ties session-specific evidence to diagnostic criteria, states severity and trajectory, and references the treatment-plan goal. A payer auditor reads Assessment first; it has to be more than a restatement of Subjective and Objective.
- Quoted speech in Subjective makes the note defensible. Each example uses at least one direct client quote. Quoted speech is harder to dispute under board review than paraphrased self-report and gives the note a real-session quality that boilerplate cannot reproduce.
- The Plan names a specific intervention, not a category. “Continue therapy” or “continue treatment plan” is not a plan; “Continue cognitive restructuring on workplace-trigger thoughts; assigned thought record specific to first hour of work day” is. Specificity in Plan is what allows a covering clinician to start the next session without a handoff call.
How Emosapien drafts mental health SOAP notes from session content
Emosapien is an AI co-therapist for talk-based therapy practice. During a session, the system tags client speech (for Subjective), observable presentation (for Objective and the MSE findings), and the active treatment-plan goal. At session end, the SOAP draft is populated with the diagnostic-criteria evidence from this session, the modality-specific intervention used, and a Plan tied to the treatment plan. The therapist reviews and signs.
The result is a draft note populated from the actual session, with diagnostic-criteria evidence and modality-specific intervention language already in place. The therapist’s job is judgment and editing rather than blank-page composition.