Soap Notes - Goal Setting
Soap Notes - Goal Setting
S- The client expressed feeling sick and unwell when she first joined the session. She also
mentioned feeling overwhelmed since her husband was away for work. The client was able to
identify a long-term goal of having greater confidence and self-esteem, and two sub-goals of
writing positive affirmations and gratitude affirmations, as well as exercising weekly. The client
mentioned having been called fat and ugly by relatives in the past. The client communicated
wanting to focus on the present rather than dwell on the past, and she expressed her desire to
spend quality time with her family and focus on things/people that matter to her.
O- The client appeared tired, and unwell as evidenced by the fact she was pale and kept blowing
her nose and coughing throughout the session. The client also seemed to be overwhelmed by her
university courses and family commitments as she mentioned feeling stressed. The client was
able to identify what might be preventing her from feeling more confident and expressed the
desire to change. The client was also able to identify some of her supports such as her husband,
and some of the things she would like to start working on to feel better such as silencing negative
thoughts.
A- The client appeared motivated to set some goals for herself and was able to identify two
SMART goals (see SMART Goals form). The client seemed to have a desire to change;
however, she often referred to and focused on the 'voices from the past' that still impact her. The
client seemed to be overwhelmed by all the commitments she is taking on, which might be due to
the fact she strives to perfection and often engages in negative self-talk rather than focusing on
her achievements.
P- Set up SMART goals with the client by focusing on an ideal world with unlimited self-esteem
and confidence. Guided a short mindfulness exercise to help the client feel grounded in the
present moment. The client was asked to review the goals set during the session and write down
any questions that might come up before the next session.
Our next appointment is Saturday, 11/05/2022 @ 2:00 PM