Adolescent SOAP Note Example for Therapists

With adolescents, the note sits between two needs: protecting the trust that makes therapeutic work possible and recording information that comes from the family or the school. It needs to be consistent with the confidentiality agreement in place and to record the risk enquiry with concrete facts.

The example below is fictional and educational. It is not a diagnostic assessment or a risk assessment, and it does not replace professional judgement or applicable documentation requirements.

Fictional adolescent SOAP note example

Context: Fifth individual session with a 15-year-old girl (fictional initial: A.). Presenting concern: low mood, conflict with her parents and a drop in school performance. At the start of the process, the limits of confidentiality were agreed with A. and her parents.

Subjective: A. reports that the week has been “a bit better”. She argued with her mother about using her phone at night, but this time she went to her room instead of shouting. She is still falling asleep late, “around two”, because she is on social media, and finds it hard to get up for secondary school. She has gone back to training with the basketball team, which she had dropped, and to meeting up with a friend from the team. When asked directly, she denies self-harm and thoughts of death in recent weeks. Before the session, her father informed the practice by message that A. has failed three subjects in the first term.

Objective: Arrives with her father, who waits outside. At first she answers in short sentences and becomes more engaged when talking about basketball. Affective expression is somewhat reduced, with moments of laughter when talking about her friend. She describes the sequence of the argument and what she did differently.

Assessment: First signs of improvement in managing family conflict and recovery of a meaningful activity and relationship. Delayed sleep associated with phone use appears to contribute to tiredness and academic difficulties, and is a source of conflict at home. Mood remains low, although with more positive reactivity. She reports no self-harm or thoughts of death in today's enquiry; continue periodic reassessment.

Plan: Agree with A. a goal of her own about phone hours, which she will decide whether to share with her parents. Consider with A. a session with her parents to work on negotiating rules, preparing in advance what will be shared. Encourage her to keep up basketball. Review mood, sleep and risk at the next session.

Why it is written this way

The father's message appears as information from the family, with its source and channel. It is not mixed with what A. explains in session.

The note is consistent with the confidentiality agreement. It records what is necessary for care and states that what is shared will be decided with A. At 15, in usual practice in Spain, consent is given by her legal representatives after hearing her views, and those who hold parental responsibility (patria potestad) have the right to be informed about the process. The confidentiality agreement can set out which specific content is shared, but it does not exclude that general information or situations of risk. The record should be written with that in mind.

The risk enquiry is recorded with what was asked and what she answered, placed in time. It is not generalised to “no risk”.

The language avoids adjectives about the adolescent, such as “defiant” or “unmotivated”, and describes specific behaviours. This is more useful for the work and fairer if the note is read later.

The same session as a progress note

Fifth individual session. Week somewhat better according to A. Argument with her mother about the phone, withdrawing to her room instead of escalating. Falls asleep around two in the morning and finds it hard to get up. Resumes basketball and contact with a friend from the team. Denies self-harm and thoughts of death on direct enquiry. Her father reports by message that she has failed three subjects. It is agreed that A. will set a goal about her phone, and a session with her parents is being considered.

Questions to use during review

• Is it clear which information comes from the adolescent and which from the family or the school?
• Is the note consistent with the confidentiality agreement in place?
• Is the risk enquiry recorded with facts and placed in time?
• Are labels about the person avoided in favour of specific behaviours?
• Is the consent required for her age and family situation recorded?

For consent with minors, see the guide on consent with minors and guardians. For the general structure, see the SOAP notes guide and the guide to mental health progress notes. You can also see the depression example or the child therapy example.

Clara prepares an editable draft from the session. The clinician decides what should go into the record according to the confidentiality agreement and reviews the risk documentation before adding it. See AI clinical notes with Clara.