SOAP Note Example: Immigration Trauma

Quill generated this note with AI from the summary that was provided. The therapist can then copy-and-paste the note into their current EHR platform.

Subjective:
Client reported feeling on edge constantly, stating, "I feel like I'm always waiting for something bad to happen." She discussed ongoing hypervigilance despite living in the U.S. for three years and attributed it to chronic stress from the immigration process, fear around her legal status, and difficulty feeling safe or settled. Client expressed grief over missing home and feeling like she lost a part of herself when she left. She also shared feelings of not fully belonging and the challenges of navigating cultural and legal uncertainties.

Objective:
60-minute virtual session. Client appeared tense and anxious. Grounding practices, including a breathing exercise (inhale for four, hold for four, exhale for six) and orienting techniques, were introduced to address hypervigilance. Therapist guided client in exploring identity and belonging, focusing on cultural reconnection through traditions, food, and community.

Assessment:
Client continues to experience heightened anxiety and hypervigilance related to immigration trauma and chronic stress. Client engaged well with grounding exercises and demonstrated openness to exploring cultural reconnection. Progress aligns with treatment goals of reducing anxiety and fostering a sense of stability and belonging.

Plan:
Client will practice grounding and breathing exercises daily and identify one way to reconnect with her culture this week. Therapist and client will meet next week to continue building supports and addressing ongoing challenges related to immigration trauma and identity.

Client Session Summary:

Here's the summary of this client session. Remember, Quill does not record the client session. A therapist would provide a summary (like the one below) after the session is over, and then Quill would generate a note similar to the one above.

We had a 60-minute virtual session today. Amara logged in and said she's been feeling on edge all the time, like she can't relax even when things are okay. She said quote 'I feel like I'm always waiting for something bad to happen' unquote. She's been in the U.S. for three years now, but the hypervigilance hasn't gone away. She talked about the chronic stress of the immigration process, the fear around her legal status, and how hard it's been to feel safe or settled when everything still feels so uncertain.

We talked about immigration trauma and how it's layered, it's not just one event, it's the relocation, the loss of community and family, the constant worry about legal and cultural stability, the discrimination and the feeling of not fully belonging anywhere. She said she misses home so much, but she also can't go back, and that grief is always with her. She said she feels like she lost a whole part of herself when she left.

We started with some grounding practices to help with the hypervigilance. I taught her a simple breathing exercise, breathe in for four, hold for four, out for six, to help calm her nervous system when the anxiety spikes. We also did some orienting, where she looked around her space and named things she could see and touch, just to help her body register that she's safe in this moment.

Right, and then we moved into some identity and belonging exploration. I asked her what parts of her culture and identity she's been able to hold onto here, and what she's had to let go of. We talked about finding small ways to reconnect with her roots, cooking traditional food, connecting with other people from her country, celebrating holidays in her own way, so she doesn't feel like she's lost all of it. Her homework is to practice the grounding and breathing exercises daily, and to pick one way to reconnect with her culture this week. She seemed a little more hopeful by the end. We'll meet again next week to keep building those supports.

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More About SOAP Notes:

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