Child Therapy SOAP Note Example

In child psychology, information arrives through several channels: what the family and the school report, what the child expresses himself and what is observed in play. The note needs to make clear where each piece of information comes from and divide the plan between what is done in session and what the family does at home.

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

Fictional child therapy SOAP note example

Context: Sixth session with an 8-year-old boy (fictional initial: L.). Presenting concern: fear of separating from his parents when going into school and of sleeping alone. His mother takes part for the first fifteen minutes and L. for the rest of the session. Cognitive behavioural approach supported by play.

Subjective: The mother reports that L. has gone into school without crying on four of the five days, compared with one in five a month ago. He still asks to sleep in his parents' bed almost every night. According to the mother, his class teacher has told her that he participates in class and plays with other children. Using the fear thermometer, L. explains that the hardest moment is “when Mum turns around” and rates it 4 out of 5. He says that on Monday he “was brave” and that he wants to earn the sticker on the challenge chart.

Objective: Stays in the consulting room without difficulty when his mother goes out to the waiting room. Uses the fear thermometer on his own initiative. In play with dolls he acts out a goodbye in which the doll “gets sad but then plays”.

Assessment: Clear improvement in separation when going into school, supported by the challenge chart and the goodbye routine agreed with the family. Night-time fear persists and is still resolved through avoidance (sleeping with his parents), which probably helps to maintain it. The information passed on from the class teacher suggests that the difficulty is concentrated in moments of separation. In play, L. can represent distress and its resolution.

Plan: With the family: introduce a gradual plan for L. to sleep in his own room, starting with his mother sitting by the bed until he falls asleep, and add it to the challenge chart. Keep the goodbye at school brief. With L.: keep using the fear thermometer and prepare a story about “the brave night” at the next session.

Why it is written this way

Each source appears separately: what the mother reports, what she passes on from the class teacher and what L. expresses in his own words.

The information from school is attributed as what it is: a comment that comes through the mother, not a direct observation or a school report. If information is later received from the school, it is best recorded with its source and date.

Play is described by what happens, without interpretations the material does not support. The assessment only includes what the play allows the clinician to state.

The plan distinguishes what the family will do at home from what will be worked on with the child, because in childhood much of the change happens outside the consulting room.

Before starting, the consent of those who hold parental responsibility (patria potestad, under Spanish law) must be recorded. In psychological care for minors in Spain, the consent of both parents is usually required, including when they are separated, unless a court ruling or a legal exception applies. The guide on consent for minors explains the most common cases.

The same session as a progress note

Sixth session, with the mother at the start. Goes into school without crying on four of five days (one in five a month ago). Co-sleeping continues almost daily. According to the mother, the class teacher reports that he participates in class and plays with other children. L. places the hardest moment at the goodbye (4 out of 5 on the fear thermometer) and acts out a goodbye with a resolution in play. A gradual plan for sleeping in his own room is agreed and added to the challenge chart.

Questions to use during review

• Is it clear what each source contributes: the child, the family and the school?
• Are observations from play described without over-interpreting them?
• Does the plan specify what the family does and what is worked on in session?
• Is the consent of the parents or guardians recorded, as appropriate?
• Is the language respectful towards the child and the family?

See the SOAP notes guide and the guide to mental health progress notes. You can also see the adolescent note example or the couples therapy example.

Clara prepares an editable draft from the session and distinguishes what each participant contributes. The clinician reviews the sources, assessment and plan before adding it to the record. See AI clinical notes with Clara.