SOAP Note (Art Therapy)

Date of Service: [Date]

Client: [Client name or identifier]

Provider: [Provider name and credentials]

Session Type: [individual / group / family; in-person / telehealth]

Duration: [Session length in minutes]

Subjective

[Session focus or presenting concern] (Include a brief direct quote only if it adds clinical value.)

[Interval history since last session] (Mood, functioning, response to prior session or between-session practice, relevant changes.)

[Client's stated meaning of the artwork] (Include only when art was made. Capture the client's explanation of imagery, symbols, story, intent, and any title assigned. Do not include therapist interpretation here.)

[Client-reported risk concerns] (If assessed, document suicidal ideation, self-harm, or safety issues as reported. If not assessed, write "Not assessed (reason: ___).")

Objective

• [Attendance and engagement]
• [General presentation] (Affect, behavior, speech, psychomotor activity—observable facts only.)
• [Intervention delivered] (Art therapy directive/prompt and therapeutic approach elements applied.)

Art Process (Include only if art was made.)

• [Materials selected]
• [Approach to task] (Planning vs. spontaneous, persistence, tolerance of ambiguity.)
• [Regulation during creation] (Arousal shifts, coping skills used, need for breaks.)
• [Communication during art-making]

Art Product (Literal description only; do not interpret. Include only if art was made.)

• [Format, size, and materials visible]
• [Color palette, line quality, space use]
• [Imagery and themes present] (Describe concretely.)
• [Degree of completion, revisions, any text]
• [Artwork disposition] (Include only if required by policy and consent is documented.)

• [Standardized measures and scores] (Include only if completed this session.)

Assessment

[Clinical synthesis] (1–2 sentences summarizing what the client presented with, what was addressed, and the clinical rationale.)

Progress toward treatment goals

• [Goal 1]: [improved / unchanged / worsened / mixed]

  [Evidence from Subjective and Objective supporting status; barriers and supports]

• [Goal 2]: [improved / unchanged / worsened / mixed]

  [Evidence; barriers and supports]

Art-therapy meaning (Include only when clinically relevant.)

• Client meaning: [Client's stated interpretation of artwork or process]
• Therapist clinical impression: [Hypotheses supported by session data; note whether client agreed. Do not infer diagnoses from artwork characteristics alone.]

Risk assessment (Include when clinically indicated.)

• [Current risk level with brief rationale]
• [Protective factors]
• [Safety plan status] (Specify changes if updated.)

[Diagnosis] (Include only if required or updated this session.)

Plan

• [Next session focus and rationale] (Include planned directives or materials if known.)
• [Between-session practice] (Specific instructions; include safety-aware alternatives if distress may arise.)
• [Care coordination or referrals] (Verify releases.)
• [Frequency or level-of-care changes] (If applicable.)
• [Risk-related actions] (Safety plan steps, crisis resources reviewed, mandatory reporting if applicable.)

Provider Signature: [Name, credentials, date/time]

Supervisor Co-signature: [If applicable]

(Omit sections that do not apply. When an expected element was not obtained, document "Not assessed (reason: ___)" or "Client declined." Do not auto-populate normal findings. Use relationship terms rather than third-party names.)