What are the essential components of a short SOAP (Subjective, Objective, Assessment, Plan) note for a patient requesting a referral for therapy?

Writing a SOAP Note for Therapy Referral

Document the patient's request for therapy in a brief SOAP note that captures their presenting concern, validates the need for referral, and establishes a clear follow-up plan to ensure they complete the first appointment. 1

Subjective Section

Document the patient's stated reason for requesting therapy, including:

• Specific symptoms or concerns the patient reports (e.g., "feeling anxious," "difficulty coping with stress," "relationship problems") 2
• Impact on daily functioning across key domains: work performance, home responsibilities, relationships, and self-care activities 1, 3
• Patient's own words and perspective about what they hope to achieve through therapy 2
• Duration and severity of symptoms if applicable 1
• Any prior mental health treatment and response to previous interventions 1

Objective Section

Include measurable clinical findings:

• Vital signs if obtained during the visit 2
• Mental status observations during the encounter (e.g., affect, mood, eye contact, engagement level) 2
• Screening tool results if administered (PHQ-9 for depression, GAD-7 for anxiety) 1
• Functional assessment findings related to the patient's ability to perform daily activities 1, 3

Assessment Section

Provide your clinical synthesis:

• Document the clinical indication for therapy referral (e.g., "Patient requesting mental health support for anxiety symptoms affecting work performance") 2, 4
• Note symptom severity level to guide appropriate referral intensity (low, moderate, or high intensity services needed) 1
• Identify any barriers to accessing care that may need to be addressed (transportation, insurance, language, cultural considerations) 1
• Document relevant psychosocial factors: substance use history, chronic medical conditions, social support, economic factors 1

Plan Section

Create a specific, actionable plan:

• Provide patient education about mental health concerns and available resources, using culturally appropriate and linguistically accessible materials 1
• Document the specific referral being made (therapist name, practice, contact information) 1
• Establish follow-up timeline to verify the patient attended their first therapy appointment (typically within 2-4 weeks) 1
• Include contact information for the patient to reach you if barriers arise 1
• Document your plan to assess patient satisfaction with services and identify any obstacles to continued treatment 1

Critical Implementation Points

Actively reduce barriers to follow-through by providing written referral information, offering to schedule the first appointment during the visit if possible, and explicitly planning how you will verify attendance. 1 Patients requesting mental health services often lack the motivation or resources to complete referrals independently, making your proactive barrier reduction essential. 1

Use a stepped-care approach when documenting the plan: match referral intensity to symptom severity, starting with the most effective yet least resource-intensive option appropriate for the patient's presentation. 1

Document any safety concerns explicitly if present, including suicidal ideation, self-harm risk, or severe functional impairment requiring urgent evaluation. 1