Edited Soap Note 1

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Megan Johnson

Client # 5525
S: Client appeared more tired than in past sessions. She was yawning throughout the meeting.
Client seemed optimistic about how things had turned out with her roommate and lacrosse coach.
She seemed more willing to talk than usual. Client appeared hopeful at the end of role-plays.
Towards the end, the client seemed relieved about the improvements she is making.
O: Client reported that she had successfully explained her disorders and situation to her
roommate. She stated this helped her to calm down, but left her feeling drained. Client said she
had made a contract with her coach and explained her disorders and substance use. She said she
was excited and slightly nervous about working towards these goals. She stated she was
disappointed with her parents because they reacted angrily and refused to speak with her. Despite
this, the client and case manager practiced facilitation skills for a discussion that will happen the
next time client sees parents at home. Client stated she felt I statements would be effective.
A: The session was progressive in that the client and case manager accomplished an important
intervention from the treatment plan. Client was well-spoken during the role-plays and
maintained proper facilitation skills. The current goal that the client and case manager are
working towards is to form a supportive and understanding relationship with her parents. This
seems to make the client apprehensive.
P: Client continues to make improvements with substance use. For the next session, the client
and case manager will further discuss her dependency on substances. Client and case manager
will make a lifeline for the history of clients substance use, focusing on when client feels most
dependent. One intervention from the treatment plan will be implemented. The next meeting with
take place on Thursday, November 21st at 9:45 A.M.

________________________________
Anna Rastatter

______________________
Date

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