Eastern Community Mental Health (ECMH) is an outpatient mental health clinic located in downtown Philadelphia. Services include substance use counseling, individual and group therapy, and a range of support groups for diverse clientele. Some clients are self-referred, whereas others are referred by healthcare providers or mandated by the court. The organization maintains a hybrid model of offering both telehealth and in-person sessions. In your current role as an advanced practice social worker, you primarily provide therapy services through telehealth.

Today is your first session with a new client, Atsumi Yoshida, who has been court-ordered to attend therapy. The referral paperwork includes several key details, though you certainly don't have a full picture of the client's circumstances:

• 42-year-old divorced female
• Three children, Jamie (13), Hana (11), and Mason (2)
• Ms. Yoshida's three children were recently taken by Child Protective Services due to neglect. The children are currently residing with family members and have supervised visitation with their mother. Ms. Yoshida has been court-ordered to attend therapy to address mental health so that she may be reunited with her children.
• You will need to report back to the social worker employed by the county regarding the attendance of Ms. Yoshida at today's session. You will use your running SOAP notes for reporting purposes.

resource

Document: SOAP Note Template (Word document)

SOAP Note

Subjective:

Objective:

Assessment:

Plan: