Clinical SOAP Note | Aspire Wellness Group Session Details Client Name DOB Date of Service Start Time End Time Duration (Mins) CPT Code 90837 (60m) 90834 (45m) H2021 (IIH) 90791 (Assessment) Location Office Telehealth (Video) Client Home Community Session Type Individual Family Crisis Subjective (S) Client Report & Presentation Objective (O) Mental Status Exam (MSE) All WNL Anxious Depressed Flat Affect Guarded Tearful Agitated Risk Assessment * No Risk Reported/Observed Suicidal Ideation Homicidal Ideation Self-Harm (NSSI) Risk Detected: Please document the Safety Plan / Crisis Intervention immediately below. Interventions Used CBT DBT Skills EMDR / Resourcing Motivational Interviewing Validation/Supportive Psychoeducation Crisis Intervention Assessment (A) Clinical Assessment & The "Golden Thread" Describe the client's response to interventions and progress toward Treatment Plan goals. Plan (P) Next Session Date Next Session Focus Homework / Tasks Signature Clinician Signature Clear Date Signed Clinician Name & Credentials Clear Form Save Draft Print / Save PDF
