Dance/Movement Therapy Session Note (SOAP, In-Person/Telehealth)

Session Information

Client Name: [Client name]

Date of Service: [Date]

Session Duration: [Duration]

Modality: [In-person / Telehealth-video / Telehealth-audio-only]

Clinician: [Clinician name, credentials]

Telehealth Compliance

(Include this section only for telehealth sessions. Omit entirely for in-person sessions.)

Identity Verified: [Verification method]

Client Location: [Address or "on file, confirmed unchanged"; include state/jurisdiction]

Consent Status: [Verbal / Written / Electronic] (Include date obtained.)

Others Present: [Names and roles on client and provider sides, or "none"]

Environment & Safety Check: [Space cleared, camera placement, physical readiness, modifications needed]

Emergency Plan: [Local emergency contact name/phone; disconnection protocol confirmed]

Technical Quality: [Adequate / Limited] (Note significant interruptions or clinical limitations if any.)

Subjective

(Document client-reported experience since last session and current state. Use brief direct quotes only when necessary to clarify symptoms, risk, or treatment response.)

• Today's Focus/Goal: [Client-stated session focus or goal]
• Interval History: [Recent stressors, supports, meaningful events since last session]
• Reported State: [Mood, affect, somatic sensations, energy, sleep, pain]
• Functioning: [ADLs, relationships, coping skill use]
• Home Practice: [Completed / Partial / None] (Include barriers if reported.)
• Movement Readiness: [New injuries, falls, medication or health changes affecting balance/energy]
• Risk Screening: [Risk domains assessed and client reports] (Include when clinically indicated or required by setting. If expected but not completed, document why.)

Objective

(Document therapist observations and session content. Use consistent descriptors.)

• Presentation: [Attendance, appearance, observed affect, engagement, orientation]
• Movement Qualities: [Posture, breath, muscle tone, rhythm, kinesphere/space use, grounding, coordination, relational movement, nonverbal affect expression] (Note changes from baseline.)
• Interventions Delivered: [Intervention types, structure/phases, props/music used, immediate client response]
• Safety Observations: [Falls, dizziness, pain behaviors, modifications needed; actions taken] (Omit if none.)

Assessment

(Provide brief clinical synthesis integrating subjective and objective data.)

• Clinical Status: [Current status synthesis and key movement/relational themes]
• Response to Session: [Effectiveness of interventions and tolerance]
• Progress Toward Goals: [Progress / Partial progress / No progress] (Cite behaviorally anchored evidence from this session.)
• Risk Formulation: [Current risk level, rationale, protective factors, actions taken] (Include only when risk concerns are present.)
• Telehealth Limitations: [Assessment limitations due to modality and mitigation steps] (Include only if modality materially affected assessment.)

Plan

• Next Session: [Planned focus, interventions, modality]
• Home Practice: [Specific practice, frequency/duration, safety stop-rules for pain/dizziness] (Omit if not assigned.)
• Coordination of Care: [Collateral contacts, referrals, ROI status] (Omit if none.)
• Follow-up: [Next appointment date/time or scheduling instructions]
• Crisis Contingencies: [When to use crisis line/911; backup contact] (Include only when clinically indicated.)

Clinician Signature / Credentials / Date-Time Signed: [Signature block]

(General guidance: Separate facts from interpretation—client-reported content in Subjective, therapist observations in Objective, clinical reasoning in Assessment. Omit optional fields not addressed. If a required field cannot be completed, document the reason.)