10 Common Social Worker SOAP Note Examples

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This page provides 10 comprehensive SOAP note examples commonly encountered in social work practice. Each example follows standard documentation guidelines and demonstrates proper clinical documentation for various client situations, from mental health concerns to child protective services and community resource coordination.

List of cases

1. Depression and Housing Instability
2. Substance Use Recovery Support
3. Child Protective Services Assessment
4. Domestic Violence Support
5. Geriatric Care Planning
6. Crisis Intervention
7. Family Therapy Session
8. Grief Counseling
9. School Social Work Intervention
10. Community Resource Navigation

1. Depression and Housing Instability

Description

The client presents with symptoms of depression complicated by housing instability and unemployment.

SOAP Note

Client Name: Maria Rodriguez

Date of Visit: 09/01/2024

Subjective

Maria Rodriguez, a 35-year-old single mother of two children (ages 8 and 11), presents with worsening depression symptoms and housing instability. Reports feeling "overwhelmed and hopeless" for the past 3 months following job loss. Currently staying with different friends, reports difficulty sleeping, decreased appetite, and constant worry about finding stable housing. PHQ-9 score: 18 (moderately severe depression). Denies suicidal ideation but expresses feeling that "life is too hard."

Objective

• Mental Status Exam:
  • Appearance: Appropriately dressed, fatigued
  • Behavior: Cooperative, tearful at times
  • Speech: Normal rate and tone
  • Mood: Depressed
  • Affect: Congruent, restricted
  • Thought Process: Linear, goal-directed
  • Thought Content: No SI/HI
  • Cognition: Alert and oriented x3
  • Insight: Good
  • Judgment: Fair
• Psychosocial Assessment:
  • Support System: Limited
  • Employment: Recently unemployed
  • Housing: Unstable
  • Financial: Significant strain
  • Children: In school, showing stress
  • Transportation: Relies on public transit
• Risk Assessment:
  • No current suicidal ideation
  • No history of attempts
  • Children as protective factor
  • Willing to engage in services

Assessment

1. Major Depressive Disorder
   • Moderately severe
   • Situational factors
   • Impact on functioning
2. Housing Instability
   • Primary stressor
   • Affects mental health
   • Impacts children
3. Unemployment
   • Contributing to depression
   • Financial strain
   • Resource needs

Plan

1. Interventions:

   • Crisis assessment completed
   • Housing resources provided
   • Employment referrals made
   • CPT Code: 90791

2. Referrals:

   • Emergency housing assistance
   • Local food bank
   • Job placement services
   • Mental health counseling

3. Support Services:

   • Weekly case management
   • Benefits application assistance
   • School liaison for children
   • Support group information

4. Follow-up:

   • Schedule within 48 hours
   • Housing application support
   • Monitor depression symptoms
   • Safety plan review

2. Substance Use Recovery Support

Description

The client presents for ongoing support in maintaining sobriety and addressing related psychosocial needs.

SOAP Note

Client Name: James Wilson

Date of Visit: 09/02/2024

Subjective

James Wilson, a 42-year-old male, presents for his weekly recovery support session. Reports 45 days of sobriety from alcohol. Describes increased cravings this week due to job-related stress. Attending daily AA meetings, has secured a sponsor. Reports improved sleep but ongoing anxiety about maintaining sobriety. Living in sober housing, following program requirements. Expresses concern about upcoming family reunion.

Objective

• Mental Status Exam:
  • Appearance: Well-groomed, alert
  • Behavior: Engaged, motivated
  • Speech: Clear, focused
  • Mood: Anxious but hopeful
  • Affect: Full range
  • Thought Process: Organized
  • Cognition: Intact
  • Insight: Improving
  • Judgment: Good
• Recovery Assessment:
  • Sobriety: 45 days
  • AA Attendance: Daily
  • Sponsor: Active relationship
  • Housing: Stable in sober living
  • Employment: Maintained
  • Support System: Growing
• Risk Factors:
  • Previous relapse history
  • Work stress identified
  • Family dynamics
  • Social pressure concerns

Assessment

1. Alcohol Use Disorder
   • Early remission
   • Active in recovery
   • Stress management needed
2. Anxiety Symptoms
   • Situational factors
   • Coping skills developing
   • Impact on recovery

Plan

1. Treatment:

   • Relapse prevention review
   • Coping skills enhancement
   • Stress management tools
   • CPT Code: 90832

2. Support Services:

   • Continue AA participation
   • Weekly group therapy
   • Sponsor relationship
   • Family counseling referral

3. Skills Development:

   • Trigger identification
   • Communication strategies
   • Boundary setting
   • Self-care planning

4. Follow-up:

   • Weekly individual sessions
   • Recovery group attendance
   • Family session scheduling
   • Progress review

3. Child Protective Services Assessment

Description

Initial assessment following report of suspected child neglect and unsafe living conditions.

SOAP Note

Client Name: Thompson Family

Date of Visit: 09/03/2024

Subjective

Home visit conducted with mother Sarah Thompson (age 29) and children Amy (age 6) and Michael (age 4). Report received through hotline regarding unsafe living conditions and possible neglect. Mother reports financial difficulties following divorce, working two jobs. Acknowledges house needs cleaning but states children are well-cared for. Children appear bonded with mother, report regular meals and school attendance.

Objective

• Home Environment Assessment:
  • Cluttered living space
  • Adequate food supply
  • Functioning utilities
  • Some safety hazards noted
  • Children have beds/clothing
• Parent-Child Interaction:
  • Appropriate attachment
  • Positive communication
  • Age-appropriate supervision
  • Children comfortable
• Children's Presentation:
  • Clean and appropriately dressed
  • Well-nourished appearance
  • Age-appropriate behavior
  • No visible injuries
• Collateral Information:
  • School reports regular attendance
  • Pediatrician confirms up-to-date
  • No previous CPS history
  • Extended family supportive

Assessment

1. Environmental Concerns
   • Moderate risk level
   • Safety hazards identified
   • Requires intervention
2. Family Strengths
   • Parent engagement
   • Children's well-being
   • Support system present
3. Resource Needs
   • Housing assistance
   • Childcare support
   • Financial planning

Plan

1. Safety Planning:

   • Home safety checklist
   • Emergency contacts established
   • Resource coordination
   • CPT Code: H0031

2. Support Services:

   • Housing assistance referral
   • Parenting support program
   • Childcare resources
   • Financial counseling

3. Monitoring:

   • Weekly home visits
   • School liaison contact
   • Progress tracking
   • Family engagement

4. Follow-up:

   • 48-hour safety check
   • Service implementation
   • Team meeting scheduled
   • Court report preparation

4. Domestic Violence Support

Description

Initial assessment and safety planning with client experiencing domestic violence.

SOAP Note

Client Name: Jennifer Chen

Date of Visit: 09/04/2024

Subjective

Jennifer Chen, a 31-year-old female, presents following referral from emergency department after domestic violence incident. Reports escalating physical and emotional abuse from husband over past year. Describes recent incident involving physical assault and threats. Expresses fear for safety but reluctant to leave due to financial dependence and cultural concerns. Has two children (ages 5 and 7) who have witnessed violence.

Objective

• Safety Assessment:
  • High risk situation
  • Recent escalation
  • Access to weapons noted
  • Children involved
  • Limited escape options
• Mental Status Exam:
  • Anxious presentation
  • Hypervigilant behavior
  • Clear communication
  • Affect constricted
  • Oriented x3
• Physical Status:
  • Visible bruising noted
  • Reports body pain
  • Sleep disruption
  • Appetite changes
• Resource Assessment:
  • Limited financial means
  • Isolated from family
  • Has smartphone access
  • Valid identification
  • Joint bank account

Assessment

1. Domestic Violence Victim
   • High risk situation
   • Safety needs immediate
   • Children at risk
2. Acute Stress Response
   • Trauma symptoms
   • Anxiety prominent
   • Requires support
3. Resource Limitations
   • Financial dependency
   • Housing needs
   • Legal assistance required

Plan

1. Safety Planning:

   • Emergency shelter discussed
   • Safety plan developed
   • Police report assistance
   • CPT Code: 90839

2. Legal Support:

   • Protection order information
   • Legal aid referral
   • Documentation assistance
   • Court advocacy available

3. Support Services:

   • DV support group
   • Children's counseling
   • Financial assistance
   • Cultural support services

4. Follow-up:

   • Daily safety checks
   • Shelter placement
   • Legal appointments
   • Children's services coordination

5. Geriatric Care Planning

Description

Assessment and care planning for elderly client with increasing care needs and declining independence.

SOAP Note

Client Name: Eleanor Davis

Date of Visit: 09/05/2024

Subjective

Eleanor Davis, an 82-year-old widow, referred by primary care physician due to concerns about declining independence. Lives alone in two-story home. Reports increasing difficulty with daily activities, particularly medication management and meal preparation. Recent falls (2 in past month), no serious injuries. Daughter lives 2 hours away, visits monthly. Client resistant to suggested assisted living placement but acknowledges need for support.

Objective

• Functional Assessment:
  • ADLs: Needs assistance with bathing
  • IADLs: Struggling with medications
  • Mobility: Uses walker
  • Fall risk: High
  • Meal preparation: Limited
• Home Safety Evaluation:
  • Multiple fall hazards
  • Poor lighting
  • Cluttered walkways
  • Stairs difficult
  • No grab bars
• Cognitive Status:
  • Alert and oriented x3
  • Short-term memory intact
  • Good insight
  • Decision-making capacity
  • MMSE: 27/30
• Support System:
  • Limited local support
  • Active church membership
  • Neighbors check in
  • Financial resources adequate

Assessment

1. Declining Independence
   • Safety concerns
   • Fall risk significant
   • Needs daily assistance
2. Social Isolation
   • Limited support network
   • Transportation barriers
   • Activity restriction
3. Care Planning Needs
   • Home modification required
   • Service coordination
   • Safety interventions

Plan

1. Care Coordination:

   • Home health evaluation
   • Safety assessment
   • Service arrangement
   • CPT Code: 99495

2. Home Modifications:

   • Grab bar installation
   • Lighting improvements
   • Decluttering assistance
   • First-floor bedroom setup

3. Support Services:

   • Meals on Wheels referral
   • Medication management
   • Transportation services
   • Senior companion program

4. Follow-up:

   • Weekly monitoring
   • Family conference
   • Service implementation
   • Ongoing assessment

6. Crisis Intervention

Description

Emergency assessment and intervention for client presenting with acute suicidal ideation.

SOAP Note

Client Name: Michael Torres

Date of Visit: 09/06/2024

Subjective

Michael Torres, a 28-year-old male, presents to emergency services with acute suicidal ideation following job loss and relationship breakup. Reports plan to overdose on medications, has pills collected. Describes feeling "completely hopeless" and "unable to go on." Recent alcohol use reported. No previous suicide attempts but history of depression. Called crisis line on friend's urging.

Objective

• Risk Assessment:
  • Active suicidal ideation
  • Specific plan present
  • Means available
  • Recent stressors acute
  • Limited protective factors
• Mental Status Exam:
  • Appearance: Disheveled
  • Behavior: Agitated
  • Mood: Severely depressed
  • Affect: Tearful
  • Speech: Pressured
  • Thought process: Disorganized
  • Orientation: Intact
  • Judgment: Impaired
• Safety Factors:
  • Friend present for support
  • Willing to engage
  • Has phone access
  • Insurance active
  • No weapons at home
• Clinical Measures:
  • PHQ-9: 24 (Severe)
  • BAC: 0.06
  • C-SSRS: High risk

Assessment

1. Acute Suicidal Risk
   • High severity
   • Active plan/means
   • Requires stabilization
2. Major Depressive Episode
   • Severe symptoms
   • Multiple stressors
   • Treatment needed
3. Alcohol Use
   • Contributing factor
   • Impairs judgment
   • Increases risk

Plan

1. Immediate Intervention:

   • Safety plan implemented
   • Voluntary admission arranged
   • Medication evaluation
   • CPT Code: 90840

2. Crisis Stabilization:

   • Inpatient placement
   • Medical clearance
   • Medication review
   • Support system activation

3. Support Services:

   • Family notification
   • Resource coordination
   • Aftercare planning
   • Crisis team involvement

4. Follow-up:

   • Daily hospital visits
   • Discharge planning
   • Outpatient setup
   • Support system engagement

7. Family Therapy Session

Description

Family therapy session addressing parent-teen conflict and communication issues.

SOAP Note

Client Name: Anderson Family

Date of Visit: 09/07/2024

Subjective

Family presents for third therapy session. Parents (John, 45, and Lisa, 43) report continued conflicts with daughter Emma (16) regarding academic performance and social media use. Emma reports feeling "constantly criticized" and "not understood." Parents express frustration with Emma's decreased grades and increased isolation. Family reports attempting communication strategies from previous session with mixed results.

Objective

• Family Dynamics:
  • High tension observed
  • Minimal eye contact
  • Defensive posturing
  • Interrupting frequent
  • Some tearfulness
• Communication Patterns:
  • Parent criticism prominent
  • Teen defensive responses
  • Limited active listening
  • Blame cycles noted
  • Some empathy attempts
• Individual Presentations:
  • Parents: Anxious, concerned
  • Teen: Withdrawn, tearful
  • All: Engaged in process
  • Willing to participate
• Progress Assessment:
  • Some technique use
  • Homework attempted
  • Insight developing
  • Motivation present

Assessment

1. Family Conflict
   • Communication barriers
   • Role transitions
   • Trust issues
2. Adolescent Struggles
   • Academic pressure
   • Social challenges
   • Identity development
3. Parenting Challenges
   • Control vs. autonomy
   • Boundary setting
   • Support methods

Plan

1. Interventions:

   • Communication exercises
   • Role-play practice
   • Boundary setting work
   • CPT Code: 90847

2. Skill Building:

   • Active listening practice
   • "I" statement usage
   • Emotion regulation
   • Conflict resolution

3. Homework:

   • Daily appreciation sharing
   • Technology contract
   • Family meeting practice
   • Progress journaling

4. Follow-up:

   • Weekly sessions
   • Individual check-ins
   • School consultation
   • Progress review

8. Grief Counseling

Description

Individual counseling session for client processing recent loss of spouse.

SOAP Note

Client Name: Margaret Wilson

Date of Visit: 09/08/2024

Subjective

Margaret Wilson, a 68-year-old female, presents for sixth grief counseling session following death of husband three months ago from cancer. Reports increased difficulty with sleeping and maintaining daily routine. Describes feeling "lost" without partner of 45 years. Experiencing anniversary reactions as wedding anniversary approaches. Reports some comfort from support group but still struggling with loneliness.

Objective

• Mental Status Exam:
  • Appearance: Well-groomed
  • Mood: Sad, wistful
  • Affect: Tearful at times
  • Speech: Normal rate/tone
  • Thought process: Linear
  • Orientation: Intact
  • Memory: Preserved
  • Insight: Good
• Grief Assessment:
  • Normal bereavement
  • No complicated grief
  • Maintaining self-care
  • Support system active
• Functional Status:
  • Sleep disrupted
  • Appetite variable
  • Activities maintained
  • Social engagement reduced
• Risk Assessment:
  • No suicidal ideation
  • Future-oriented
  • Spiritual connection
  • Family support present

Assessment

1. Uncomplicated Bereavement
   • Acute grief phase
   • Normal progression
   • Anniversary reaction
2. Adjustment Challenges
   • Role transition
   • Identity reformation
   • Daily routine changes
3. Support Needs
   • Social connection
   • Emotional processing
   • Practical assistance

Plan

1. Therapeutic Interventions:

   • Grief processing
   • Coping strategies
   • Memory integration
   • CPT Code: 90837

2. Support Services:

   • Continue grief group
   • Senior center referral
   • Volunteer opportunities
   • Social activities

3. Coping Skills:

   • Journaling exercises
   • Meditation practice
   • Memory book creation
   • Self-care planning

4. Follow-up:

   • Weekly sessions
   • Group attendance
   • Activity monitoring
   • Support system check

9. School Social Work Intervention

Description

Assessment and intervention for student presenting with behavioral issues and academic decline.

SOAP Note

Client Name: Kevin Martinez

Date of Visit: 09/09/2024

Subjective

Kevin Martinez, a 13-year-old 8th-grade student, referred by teachers due to increasing behavioral issues and academic decline. Student reports feeling "picked on" by peers and "bored" in classes. Recently moved to district following parents' divorce. Mother reports changes in behavior at home, including increased isolation and anger outbursts. Academic performance dropped from B average to D's in current quarter.

Objective

• School Performance:
  • Attendance: 85%
  • Multiple incomplete assignments
  • Disruptive in class
  • Test scores declining
  • Frequent tardiness
• Behavioral Observations:
  • Withdrawn from peers
  • Defensive with adults
  • Anger outbursts noted
  • Poor impulse control
  • Some positive peer interactions
• Academic Assessment:
  • Reading level at grade
  • Math skills adequate
  • Work completion poor
  • Organization lacking
  • Capable of grade-level work
• Social Assessment:
  • Limited peer relationships
  • Some bullying reported
  • Lunch period isolation
  • Teacher conflicts
  • Support staff rapport good

Assessment

1. School Adjustment Issues
   • Transition difficulties
   • Academic decline
   • Behavioral concerns
2. Family Stress Impact
   • Divorce adjustment
   • Communication needs
   • Support system changes
3. Social-Emotional Needs
   • Peer relationship skills
   • Anger management
   • Self-advocacy development

Plan

1. School Interventions:

   • Behavior support plan
   • Teacher consultation
   • Academic support
   • CPT Code: H0004

2. Support Services:

   • Counseling group placement
   • Mentor program
   • Homework club
   • Social skills group

3. Family Support:

   • Parent consultation
   • Resource coordination
   • Communication plan
   • Progress monitoring

4. Follow-up:

   • Weekly check-ins
   • Teacher updates
   • Parent communication
   • Progress review

10. Community Resource Navigation

Description

Assessment and assistance for client seeking multiple community resources and services.

SOAP Note

Client Name: Sandra Phillips

Date of Visit: 09/10/2024

Subjective

Sandra Phillips, a 42-year-old single mother of three (ages 7, 10, 14), presents seeking assistance with multiple resource needs following recent layoff. Reports struggling with rent payment, utility bills, and food security. Currently receiving unemployment benefits but insufficient for expenses. Has medical needs for youngest child with asthma. Seeking job training opportunities and affordable childcare options.

Objective

• Resource Assessment:
  • Income: Unemployment only
  • Housing: At risk
  • Food: SNAP pending
  • Healthcare: Medicaid eligible
  • Transportation: Limited
• Family Needs:
  • Childcare required
  • Medical management
  • Educational support
  • Employment training
  • Emergency assistance
• Current Supports:
  • Extended family limited
  • Church connection
  • School resources
  • Previous work experience
  • Computer access
• Barriers:
  • Transportation issues
  • Childcare costs
  • Healthcare gaps
  • Skills updating needed
  • Language barriers

Assessment

1. Economic Crisis
   • Multiple needs
   • Resource gaps
   • Immediate priorities
2. Family Stability Risks
   • Housing insecurity
   • Healthcare needs
   • Childcare issues
3. Employment Barriers
   • Skill development needed
   • Childcare dependent
   • Transportation limits

Plan

1. Immediate Assistance:

   • Emergency rent help
   • Utility assistance
   • Food bank referral
   • CPT Code: H0023

2. Resource Coordination:

   • SNAP application
   • Medicaid enrollment
   • Childcare vouchers
   • Job training program

3. Support Services:

   • Career counseling
   • Budget planning
   • Healthcare navigation
   • Educational support

4. Follow-up:

   • Weekly monitoring
   • Application tracking
   • Service coordination
   • Progress assessment