write SOAP NOTE : Mr. Coleman is a 29 year old single African American male; presented neatly dressed, dressed appropriate for the weather. His appareance was congruity with his stated age. He stated that he stays sometimes with his mother and other ti

**SOAP NOTE** **Patient Name:** Mr. Coleman **Date:** [Insert Date] **Clinician:** [Insert Clinician’s Name] **Subjective:** Mr. Coleman is a 29-year-old single African American male who presented neatly dressed and appropriately for the weather. He reports feelings of being “okay” and does not exhibit any perceptual abnormalities such as hallucinations, illusions, or delusions. He states that he sometimes resides with his mother and other times with his girlfriend. Mr. Coleman expressed concerns about his probation officer’s requests for urine specimens, showing a sense of paranoia regarding potential legal repercussions (“is she trying to put me back to jail or what?”). He denies any suicidal or homicidal ideation and does not report any attempts. Mr. Coleman’s father, who is also homeless, accompanied him to the session, assisting in efforts to help his son secure permanent housing. Mr. Coleman demonstrates minimal progress towards his recovery goals. When asked about resuming intramuscular injections that have been beneficial for him in the past, he stated, “not really but I think about it.” He described his negative feelings towards the injection, referring to it as making him feel slow and like a “zombie,” which he associates with the desire to use marijuana and synthetic weed. **Objective:** - Appearance: Neatly dressed, appropriate for the weather. - Mood: “I am okay.” - Affect: Congruent with mood. - Thought Process: Paranoid - Insight: Limited; struggles with thoughts about medication and recovery. - No signs of hallucinations, delusions, or suicidal/homicidal ideation. - Support System: Father present, actively involved in seeking housing. **Assessment:** Mr. Coleman appears to be struggling with paranoia regarding his probation officer and their intentions. While he denies significant mental health crises, there are underlying issues related to housing instability and substance use. His understanding of the benefits of medication is limited; he shows ambivalence toward resuming intramuscular injections due to perceived negative side effects. His current state of minimal goal achievement indicates a need for further support and possible reevaluation of recovery strategies. **Plan:** 1. Continue to explore Mr. Coleman’s feelings about housing and the impact of homelessness on his mental health during future sessions. 2. Provide education on the benefits of medication, including intramuscular injections, while addressing his concerns regarding side effects. 3. Encourage a discussion on coping strategies for managing feelings of paranoia and anxiety regarding his probation. 4. Involve family (father) as a potential support system in discussions about housing and recovery. 5. Schedule a follow-up appointment in one week to monitor progress and adjust the treatment plan as needed.