SOAP note example for Counselor

SOAP note example for Counselor

Subjective section

David states that he continues to experience cravings for heroin. He desperately wants to drop out of his methadone program and revert to what he was doing. David is motivated to stay sober by his daughter and states that he is "sober, but still experiencing terrible withdrawals" He stated that [he] "dreams about heroin all the time, and constantly wakes in the night drenched in sweat."

Objective observations

David was prompt to his appointment; he filled out his patient information sheet quietly in the waiting room and was pleasant during the session. He did not display signs of being under the influence. David remains aroused and distractible, but his concentration has improved. This was indicated through his discussion with me about his partner for fifteen minutes and his ability to reflect on his history. David's personal hygiene and self-care have markedly improved. His physical exam report demonstrated that he had gained 3pounds.

Assessment Section

David is making significant progress. He applies skills such as control techniques, exercises and he is progressing in his treatment. His cravings have reduced from "constant" to "a few times an hour." David continues to experience regular cravings with a 5-year history of heroin use. David needs to acquire and employ additional coping skills to stay on the same path. David is doing well, but there is significant clinical reasoning to state that David would benefit from CBT treatment as well as extended methadone treatment.

Plan

David has received a significant amount of psychoeducation within his therapy session. The therapist will begin to use dialectical behavioral therapy techniques to address David's emotion dysregulation. David also agreed to continue to hold family therapy sessions with his wife. Staff will continue to monitor David regularly in the interest of patient care and his past medical history.

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