S.O.A.P. Notes
Subjective, Objective, Assessment, and Plan
Subjective:
Subjective experience of the client as related/reported by the client. Often direct quotes from the client of his/her problems or complaints. Examples include, “I had an awful week,” “I’m feeling really depressed,” “I hate my mother,” “I can’t seem to stop worrying about my grade,” “I haven’t slept in two days,” etc. Also can be statements made by client that you summarize without using quotes.
Objective:
An objective account of the client appearance and behaviors. May include client dress/clothing, posturing, eye contact, timeliness to session, affect, activity, speech, etc. All the information in this section should be objective in the sense that it could be verified by observers and contains no analysis/judgment on your part. The Objective section should provide a behavioral picture of the client.
Assessment:
Your theory-specific analysis or interpretation of the client’s issues and the session. Examples include, “The client seemed to accept his anger” or “The client’s thinking was irrational in the following ways ….” This is your chance to hypothesize and define your conceptualization of your client’s issues.
Plan:
What you plan to do in the next session. Includes homework assignments, planned exercises or techniques, etc. When writing this section, ask yourself, “Following this theory, what is it I want to remember to do with this client?” or “What do I want to cover with them next week?” A plan should always be theory-specific.
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B.I.R.P. Notes
Behavior, Intervention, Response, and Plan
B Behavior
Counselor observation, client statements.
1. Subjective data about the client—what are the client’s observations, thoughts, direct quotes?
2. Objective data about the client—what does the counselor observe during the session (affect,mood, appearance)?
I Intervention
Counselor’s methods used to address goals and objectives, observation, client statements.
3. What is the counselor’s understanding about the problem?
4. What are the counselors’ working hypotheses?
5. What was the general content and process of the session?
6. Was homework reviewed (e.g., journal, reading assignments – if any)?
7. What goals, objectives were addressed this session?
R Response
Client’s response to intervention and progress made toward tx plan goals and objectives
8. Client’s response to the treatment plan, what needs revision?
9. What is the client’s current response to the treatment plan?
P Plan
Document what is going to happen next
10. What in the treatment plan needs revision?
11. What is the counselor going to do next?
12. When is the next session date?
General Checklist
13. Does this note connect to the client’s individualized treatment plan?
14. Are client strengths/limitations in achieving goals noted and considered?
15. Is this note dated, signed, and legible?
16. Is the client name and identifier included on each page?
17. Has referral information been documented?
18. Does note reflect changes in client status (e.g., GAF Scale, measures of functioning)?
19. Are any abbreviations used standardized and consistent?
20. Would someone not familiar with this case be able to read this note and understand exactly
what has occurred in treatment?
21. Are any non-routine calls, missed sessions, or professional consultations regarding this case documented?
22. Did counselor/supervisor sign note?
Treatment Planning M.A.T.R.S.:
Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful Module 4 – Handout 7
Counselor observation, client statements.
1. Subjective data about the client—what are the client’s observations, thoughts, direct quotes?
2. Objective data about the client—what does the counselor observe during the session (affect,mood, appearance)?
I Intervention
Counselor’s methods used to address goals and objectives, observation, client statements.
3. What is the counselor’s understanding about the problem?
4. What are the counselors’ working hypotheses?
5. What was the general content and process of the session?
6. Was homework reviewed (e.g., journal, reading assignments – if any)?
7. What goals, objectives were addressed this session?
R Response
Client’s response to intervention and progress made toward tx plan goals and objectives
8. Client’s response to the treatment plan, what needs revision?
9. What is the client’s current response to the treatment plan?
P Plan
Document what is going to happen next
10. What in the treatment plan needs revision?
11. What is the counselor going to do next?
12. When is the next session date?
General Checklist
13. Does this note connect to the client’s individualized treatment plan?
14. Are client strengths/limitations in achieving goals noted and considered?
15. Is this note dated, signed, and legible?
16. Is the client name and identifier included on each page?
17. Has referral information been documented?
18. Does note reflect changes in client status (e.g., GAF Scale, measures of functioning)?
19. Are any abbreviations used standardized and consistent?
20. Would someone not familiar with this case be able to read this note and understand exactly
what has occurred in treatment?
21. Are any non-routine calls, missed sessions, or professional consultations regarding this case documented?
22. Did counselor/supervisor sign note?
Treatment Planning M.A.T.R.S.:
Utilizing the Addiction Severity Index (ASI) to Make Required Data Collection Useful Module 4 – Handout 7
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D.A.P. Notes
Description, Analysis/Assesment, and Plan
Description:
What happen? What's going on with the client? Here you will give your interepretation of what is going on with the client as well as what they client states is going on. Be detailed orientated here because this gives you help with writing your quarterly reports.
Analysis/Assessment:
Your theory-specific analysis or interpretation of the client’s issues and the session. Examples include, “The client seemed to accept his anger” or “The client’s thinking was irrational in the following ways ….” This is your chance to hypothesize and define your conceptualization of your client’s issues.
Plan:
What you plan to do in the next session. Includes homework assignments, planned exercises or techniques, etc. When writing this section, ask yourself, “Following this theory, what is it I want to remember to do with this client?” or “What do I want to cover with them next week?” A plan should always be theory-specific.
What happen? What's going on with the client? Here you will give your interepretation of what is going on with the client as well as what they client states is going on. Be detailed orientated here because this gives you help with writing your quarterly reports.
Analysis/Assessment:
Your theory-specific analysis or interpretation of the client’s issues and the session. Examples include, “The client seemed to accept his anger” or “The client’s thinking was irrational in the following ways ….” This is your chance to hypothesize and define your conceptualization of your client’s issues.
Plan:
What you plan to do in the next session. Includes homework assignments, planned exercises or techniques, etc. When writing this section, ask yourself, “Following this theory, what is it I want to remember to do with this client?” or “What do I want to cover with them next week?” A plan should always be theory-specific.
Millage Form
How much do you reimburse my worker per mile?
We currently reimburse at the rate of $ .35 per mile. Our rates are subject to change.
How many miles of reimbursement am I eligible to receive?
- Each person’s needs are different and the STAR program can accommodate different needs. Anyone who meets the eligibility criteria will have up to 300 miles per month for which they may be reimbursed. As with the rate of reimbursement, the monthly maximum is subject to change based on funding and budgetary considerations.
Trip Tracking & Reimbursement
How do I track my trips?
- Once you have been approved to use the STAR program, you will be given a reimbursement form used to track all trip details. You will also be given a handbook explaining in detail how to use the reimbursement form.
Can my driver help me track trips?
- Yes; both the driver and the passenger must sign the reimbursement form before submitting it at the end of each month.
If I have more than one driver can I combine trips on one form?
- It is best to keep separate records for each driver. However, the reimbursement form is double sided and you may use one side for one driver and the other side for your second driver. In any case, each driver as well as the passenger must sign the reimbursement form verifying the accuracy of the mileage being reported.
Can I record trips from different months on the same form?
- No; the STAR program can only process reimbursements one month at a time.
When are the reimbursement forms due?
- Reimbursement forms are due no later than the 14th of the month after the month in which you traveled. For example, trips on January’s reimbursement form are due by February 14th; trips in February are due by March 14th, and so on.
How will my driver be reimbursed?
- STAR program will send a check to the passenger. The passenger then reimburses the driver. Simple as that!
If I have more than one driver, will I get more than one reimbursement check?
- No; your reimbursement forms will be processed and a single check will be made to the passenger for the total dollar amount. It is the passenger’s responsibility to reimburse each driver appropriately.
Will my volunteer driver be reimbursed for the distance they drive?
Yes; as stated above, services must be pre-approved and rendered. However at no times are to pay your worker for assistance. We are NOT a transportation agency. If you need transportation assistance for services that are not within the scope of Le Blanc Consulting. We will provide a referral to one of our community partners that provide transportation services.
Can I use the LeBlanc Consulting programs outside of Alameda or Contra Costa County?
Yes, so long as you are PRE-Approved by your RC Social Worker and Le Blanc Consulting to be determined during the eligibility process.
We currently reimburse at the rate of $ .35 per mile. Our rates are subject to change.
How many miles of reimbursement am I eligible to receive?
- Each person’s needs are different and the STAR program can accommodate different needs. Anyone who meets the eligibility criteria will have up to 300 miles per month for which they may be reimbursed. As with the rate of reimbursement, the monthly maximum is subject to change based on funding and budgetary considerations.
Trip Tracking & Reimbursement
How do I track my trips?
- Once you have been approved to use the STAR program, you will be given a reimbursement form used to track all trip details. You will also be given a handbook explaining in detail how to use the reimbursement form.
Can my driver help me track trips?
- Yes; both the driver and the passenger must sign the reimbursement form before submitting it at the end of each month.
If I have more than one driver can I combine trips on one form?
- It is best to keep separate records for each driver. However, the reimbursement form is double sided and you may use one side for one driver and the other side for your second driver. In any case, each driver as well as the passenger must sign the reimbursement form verifying the accuracy of the mileage being reported.
Can I record trips from different months on the same form?
- No; the STAR program can only process reimbursements one month at a time.
When are the reimbursement forms due?
- Reimbursement forms are due no later than the 14th of the month after the month in which you traveled. For example, trips on January’s reimbursement form are due by February 14th; trips in February are due by March 14th, and so on.
How will my driver be reimbursed?
- STAR program will send a check to the passenger. The passenger then reimburses the driver. Simple as that!
If I have more than one driver, will I get more than one reimbursement check?
- No; your reimbursement forms will be processed and a single check will be made to the passenger for the total dollar amount. It is the passenger’s responsibility to reimburse each driver appropriately.
Will my volunteer driver be reimbursed for the distance they drive?
Yes; as stated above, services must be pre-approved and rendered. However at no times are to pay your worker for assistance. We are NOT a transportation agency. If you need transportation assistance for services that are not within the scope of Le Blanc Consulting. We will provide a referral to one of our community partners that provide transportation services.
Can I use the LeBlanc Consulting programs outside of Alameda or Contra Costa County?
Yes, so long as you are PRE-Approved by your RC Social Worker and Le Blanc Consulting to be determined during the eligibility process.
