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Intro to MFT

SOAP Note Class Assignment

1 | Session Notes Example 04.25.2025

Initial Session Date: Client Name:

Case Number:

Session Participants (list everyone in the room other than the therapist):

Start Time: ______________________

End Time: _______________________

Duration: _______________________

Program Name:

Chief Complaint and Timeframe of Onset: ___________________________________________________________________________________

___________________________________________________________________________________

Subjective Report: ___________________________________________________________________________________

___________________________________________________________________________________

Objective Findings: ___________________________________________________________________________________

___________________________________________________________________________________

__________________________________________________________________________________

Intro to MFT

SOAP Note Class Assignment

2 | Session Notes Example 04.25.2025

Assessment Progress: ___________________________________________________________________________________

___________________________________________________________________________________

Co-Constructed Goal:

Long Term Goal 1: ___________________________________________________________________

___________________________________________________________________________________

Short Term Goal 1:

____________________________________________________________________________

Short Term Goal 2:

____________________________________________________________________________

Interventions:

____________________________________________________________________________

Plan Details:

___________________________________________________________________________________

Intro to MFT

SOAP Note Class Assignment

3 | Session Notes Example 04.25.2025

___________________________________________________________________________________

Suggested Frequency of Sessions: ______________________________________________________

Suggested Duration of Sessions: _______________________________________________________

CPT Code (s):

Date of next session: _______________ ________________________________ ____________________________________ Student Therapist Name Student Therapist Signature

CPT Codes and Description

90832 PSYTX W PT 30 MINUTES

90834 PSYTX W PT 45 MINUTES

90837 PSYTX W PT 60 MINUTES

90839 PSYTX CRISIS INITIAL 60 MIN

90840 PSYTX CRISIS EA ADDL 30 MIN 90846 FAMILY PSYTX W/O PT 50 MIN

90847 FAMILY PSYTX W/ PT 50 MIN

Date: 10/5/25
Client Name: Bill & Leslie
Case Number:
Session Participants list everyone in the room other than the therapist: Leslie (wife) Bill (husband)
Start Time: 12:00
Program Name: Family Therapy Clinic
End Time: 13:00
Duration: 60 minutes
Chief Complaint and Timeframe of Onset 1: CLs present with increase in marital conflict and emotional disconnect. Wife reports feeling alone in household duties while husband feels misunderstood about his demanding work schedule.
Subjective Report 1: CLs attend therapy for ongoing marital conflict. Wife reported feeling emotionally and physically unsupported, expressing that she carries the majority of responsibilities for their two young children stating, "Our kids dont even know him." She voiced concerns about Bills interactions with female colleagues, his long work hours. and emotional distance. Husband reported frustration that wife does not understand the demands of his job and believes his current workload is necessary to secure financial stability for their family's future. Both partners acknowledged frequent arguments and feelings of disconnection. Each expressed a desire to improve the relationship and identified love as still present.
Objective Findings 1: Both clients were alert and oriented x4. Their appearances were appropriate for the therapeutic setting. Leslie's mood appeared anxious and frustrated, with affect congruent to content as evidenced by tearfulness, tense posture, and frequent sighing. Bill's mood appeared guarded and defensive initially, with affect becoming more relaxed and open as the session progressed, evidenced by increased eye contact, softening tone, and smiling during later discussion. Both clients demonstrated organized thought processes as evidenced by coherent and goal-directed verbalizations throughout the session.
Assessment Progress 1: CLs differing perceptions of work, home roles, and intimacy have contributed to resentment and emotional distance.Protective factors include mutual love, willingness to engage in therapy, and openness to change demonstrated during the scaling and miracle question exercises. Presenting issues align with relationship dissatisfaction, emotional disconnection, and role strain within the marital subsystem.
CoConstructed Goal:
Long Term Goal 1 1: Rebuild trust and closeness while balancing work/family; reduce escalations; establish clear agreements about parenting roles and finances.
Short Term Goal 1 1: Bill will increase communication by calling Leslie during the day and participating in the children's bedtime routine at least three times per week.
Interventions 1: Solution-Focused (miracle/scaling), exploring emotional needs, communication skill-building, and establishing weekly check-ins to strengthen connection.
Plan Details 1: CLs will continue attending conjoint therapy weekly to strengthen emotional connection, improve communication, and increase shared involvement in family responsibilities. CLs will identify one family activity to complete together before the next session to reinforce bonding and teamwork.
2:
undefined: 1x a week
Suggested Duration of Sessions: 3 months
CPT Code s: 90837
Date of next session: 10/12/25
Student Therapist Name: Julia Galiszewski
Text1: Leslie will express appreciation for Bill's efforts and engage in positive interactions (e.g., greeting, physical affection) at least three times per week.