Grief Counseling SOAP Note (Psychotherapy)

Encounter Details

Patient Name: [Patient full name]

DOB/MRN: [DOB / MRN]

Date of Service: [Date]

Session Time: [Start–stop times or total psychotherapy minutes] (Required for time-based billing)

Modality: [in-person / telehealth audio-video / telehealth audio-only]

Patient Location (telehealth): [City/State; note any assessment limitations from modality] (Only include for telehealth encounters)

Subjective

Session focus: [Chief concern or presenting focus of today's visit]

[Narrative summary of interval grief experiences since last session] (Synthesize prominent grief-related experiences as reported—yearning, sadness, guilt, avoidance, intrusive memories, meaning/identity disruption as relevant. Integrate changes in functioning, coping strategies, and support system utilization. If between-session homework was assigned, summarize completion and barriers. Write in respectful, patient-centered language; avoid verbatim dialogue.)

Safety assessment: [Patient report on suicidal ideation (passive/active), intent, plan, self-harm urges, and protective factors] (Explicitly document presence or absence. If safety was not fully assessed, state why and what mitigation occurred—never leave blank or infer denial.)

Objective

Observations: [Appearance, engagement, affect, speech, psychomotor activity] (Document clinician-observed findings only; patient-reported history belongs in Subjective.)

Targeted MSE: [Orientation, thought process, thought content, insight/judgment as clinically indicated] (Include when elevated risk, diagnostic uncertainty, deterioration, or periodic review warrants; omit if routine presentation.)

Standardized measures: [Tool name, score, brief interpretation] (Only if administered this session; otherwise omit.)

Telehealth observation constraints: [Observation limitations due to audio/video quality or setting] (Include for telehealth when applicable; otherwise omit.)

Assessment

[1–3 sentence clinical formulation synthesizing current grief trajectory, maintaining factors, and strengths/protective factors] (Provide integrative summary; avoid restating raw data.)

Diagnostic impression: [Working clinical impression or active DSM/ICD diagnosis] (Clarify whether symptoms reflect expected bereavement distress versus clinically impairing persistent grief. Note relevant comorbidities if present.)

Risk level: [low / moderate / high] — [Brief rationale citing key risk drivers and protective factors]

Progress toward treatment goals: [improved / unchanged / worsened] — [Concise rationale referencing engagement, insight, skill acquisition, or functional change]

Plan

Interventions today: [Techniques and modalities used with brief target] (e.g., supportive psychotherapy, grief psychoeducation, cognitive restructuring, behavioral activation, graded exposure, mindfulness/grounding, narrative/meaning-making work, safety planning as applicable)

Between-session tasks: [Specific homework linked to treatment goals; note patient agreement] (Omit if none assigned.)

Safety plan: [Crisis resources provided; means safety steps; emergency contact/location plan for telehealth] (Include when risk is above low or otherwise clinically indicated; omit if not needed.)

Coordination/Referrals: [Referrals or coordination with other providers] (Only include if initiated this session.)

Follow-up: [Next appointment date/time, frequency, modality, and conditions for earlier contact]

Signature

Clinician Signature: [Name]

Credentials: [Degree/license]

Date/Time Signed: [Date/time]

(Omit sections or fields not relevant to the encounter rather than leaving placeholders, except for the safety assessment which requires explicit documentation each session. Avoid verbatim session content; document themes and clinical formulations.)