This is an unusual request because a **SOAP note** is a clinical documentation format used for patient
encounters. However, I have created a hybrid resource for you: (1) a **Counseling Session SOAP Note**
applying the SOAP framework to a substance use disorder case study, and (2) a **200-question
comprehensive practice exam** covering all IC&RC ADC exam domains for 2025/2026.
---
## 📋 PART 1: COUNSELING SESSION SOAP NOTE
### (Substance Use Disorder Clinical Documentation)
The SOAP note is the standard documentation format for clinical encounters. This demonstrates the
clinical documentation skills tested on the ADC exam.
---
### S: SUBJECTIVE (Client-Reported Information)
,**Client Initials:** T.W. | **Age:** 34 | **Gender:** Male | **Date of Encounter:** [Current Date]
**Admission Date:** [Date] | **Session Number:** 6
**Location:** Outpatient Substance Use Treatment Center
**Chief Complaint (in client's own words):**
> *"I'm not sure I can do this. My wife is going to leave me if I don't get clean, but every time I try to
stop, I just can't handle it."*
**History of Present Illness:**
T.W. is a 34-year-old male with a diagnosed Opioid Use Disorder (severe) who presents for his 6th
individual counseling session. He reports craving opioids "several times a day," particularly in the
evenings. He states, "I've been clean for 4 weeks, but yesterday I almost called my dealer." He reports
poor sleep (awakening 3-4 times per night), low energy, and anhedonia. No alcohol or other substances
reported since admission. He denies current SI/HI.
**Substance Use History:**
- **Primary substance:** Heroin (intranasal, ~0.5g daily for 2 years; previously IV but stopped 6 months
ago due to abscess)
- **Secondary substances:** Occasional benzodiazepines (alprazolam, non-prescribed)
- **Tobacco:** 1 pack/day (reports wanting to quit but "not ready")
- **Previous treatment:** Completed detox once (2023), 30-day residential (relapsed within 2 weeks)
**Current Medications (from chart review):**
- **Methadone** 80 mg daily (observed daily dosing at clinic)
- **Sertraline** 100 mg daily (prescribed by psychiatrist)
- **Nicotine patch** 21 mg daily
**Psychosocial History:**
- **Living situation:** Lives with wife and two children (ages 6 and 8) in rented apartment
- **Employment:** Unemployed for 8 months (previously construction worker)
,- **Legal history:** One DUI (2022), no current legal involvement
- **Support system:** Wife described as "supportive but exhausted"; parents live out of state
- **Trauma history:** Reports childhood emotional neglect; denies physical/sexual abuse
**Review of Systems (pertinent positives):**
- **General:** Fatigue, reduced appetite (lost 12 lbs since admission)
- **Psychiatric:** Anhedonia, low mood, craving, sleep disturbance, mild anxiety
- **GI:** Reports occasional nausea (methadone-related)
- No other acute medical complaints
---
### O: OBJECTIVE (Clinical Observations & Data)
**Vital Signs (today):**
| BP | HR | RR | Temp | Weight |
|----|----|----|------|--------|
| 118/72 | 78 | 14 | 98.2°F | 178 lbs (stable) |
**Counseling Session Observations:**
- **Appearance:** Casually dressed, slightly disheveled; appears stated age; some dental erosion noted
- **Behavior:** Cooperative but fidgety; maintains intermittent eye contact; late for session by 8
minutes
- **Speech:** Normal rate, volume, and rhythm; clear articulation
- **Mood:** "Anxious and frustrated" (client's words)
- **Affect:** Constricted but reactive; dysthymic quality; some irritability when discussing cravings
- **Thought Process:** Linear and goal-directed
- **Thought Content:** Preoccupied with cravings and fear of relapse; no delusions, no paranoid
ideation
, - **Perceptual Disturbances:** None reported
- **Cognition:** Alert and oriented x4; attention/concentration fair (some distractibility)
- **Insight:** Fair (acknowledges addiction as a problem but ambivalent about specific changes)
- **Judgment:** Fair (recognizes relapse risk but struggles with coping)
- **Risk Assessment:** Denies SI, HI, or self-harm; expressed fear about relapse but no plan
**Screening Instruments (completed this session):**
| Instrument | Score | Interpretation |
|------------|-------|----------------|
| **CRAFFT** (applicable as history indicates adolescent onset) | N/A | History of early use (age 15) |
| **Addiction Severity Index (ASI)** | Referenced from intake | Highest severity in drug use,
family/social, psychiatric domains |
| **Clinical Opiate Withdrawal Scale (COWS)** | 4 | Minimal withdrawal (stable on methadone) |
**Relevant Laboratory Data (from chart review):**
| Test | Result | Date | Significance |
|------|--------|------|--------------|
| UDS | Negative for all substances | Yesterday | Confirms 4 weeks abstinence |
| Hepatitis C antibody | Positive | Intake | Requires medical follow-up |
| Liver enzymes | ALT 68, AST 72 | Intake | Mild elevation |
**Stage of Change Assessment (Prochaska & DiClemente):**
Based on session content and behavior, T.W. is assessed to be in the **Contemplation Stage** of
change . He acknowledges the problem and expresses ambivalence about change ("I'm not sure I can do
this").
---
### A: ASSESSMENT (Clinical Analysis & Diagnosis)
encounters. However, I have created a hybrid resource for you: (1) a **Counseling Session SOAP Note**
applying the SOAP framework to a substance use disorder case study, and (2) a **200-question
comprehensive practice exam** covering all IC&RC ADC exam domains for 2025/2026.
---
## 📋 PART 1: COUNSELING SESSION SOAP NOTE
### (Substance Use Disorder Clinical Documentation)
The SOAP note is the standard documentation format for clinical encounters. This demonstrates the
clinical documentation skills tested on the ADC exam.
---
### S: SUBJECTIVE (Client-Reported Information)
,**Client Initials:** T.W. | **Age:** 34 | **Gender:** Male | **Date of Encounter:** [Current Date]
**Admission Date:** [Date] | **Session Number:** 6
**Location:** Outpatient Substance Use Treatment Center
**Chief Complaint (in client's own words):**
> *"I'm not sure I can do this. My wife is going to leave me if I don't get clean, but every time I try to
stop, I just can't handle it."*
**History of Present Illness:**
T.W. is a 34-year-old male with a diagnosed Opioid Use Disorder (severe) who presents for his 6th
individual counseling session. He reports craving opioids "several times a day," particularly in the
evenings. He states, "I've been clean for 4 weeks, but yesterday I almost called my dealer." He reports
poor sleep (awakening 3-4 times per night), low energy, and anhedonia. No alcohol or other substances
reported since admission. He denies current SI/HI.
**Substance Use History:**
- **Primary substance:** Heroin (intranasal, ~0.5g daily for 2 years; previously IV but stopped 6 months
ago due to abscess)
- **Secondary substances:** Occasional benzodiazepines (alprazolam, non-prescribed)
- **Tobacco:** 1 pack/day (reports wanting to quit but "not ready")
- **Previous treatment:** Completed detox once (2023), 30-day residential (relapsed within 2 weeks)
**Current Medications (from chart review):**
- **Methadone** 80 mg daily (observed daily dosing at clinic)
- **Sertraline** 100 mg daily (prescribed by psychiatrist)
- **Nicotine patch** 21 mg daily
**Psychosocial History:**
- **Living situation:** Lives with wife and two children (ages 6 and 8) in rented apartment
- **Employment:** Unemployed for 8 months (previously construction worker)
,- **Legal history:** One DUI (2022), no current legal involvement
- **Support system:** Wife described as "supportive but exhausted"; parents live out of state
- **Trauma history:** Reports childhood emotional neglect; denies physical/sexual abuse
**Review of Systems (pertinent positives):**
- **General:** Fatigue, reduced appetite (lost 12 lbs since admission)
- **Psychiatric:** Anhedonia, low mood, craving, sleep disturbance, mild anxiety
- **GI:** Reports occasional nausea (methadone-related)
- No other acute medical complaints
---
### O: OBJECTIVE (Clinical Observations & Data)
**Vital Signs (today):**
| BP | HR | RR | Temp | Weight |
|----|----|----|------|--------|
| 118/72 | 78 | 14 | 98.2°F | 178 lbs (stable) |
**Counseling Session Observations:**
- **Appearance:** Casually dressed, slightly disheveled; appears stated age; some dental erosion noted
- **Behavior:** Cooperative but fidgety; maintains intermittent eye contact; late for session by 8
minutes
- **Speech:** Normal rate, volume, and rhythm; clear articulation
- **Mood:** "Anxious and frustrated" (client's words)
- **Affect:** Constricted but reactive; dysthymic quality; some irritability when discussing cravings
- **Thought Process:** Linear and goal-directed
- **Thought Content:** Preoccupied with cravings and fear of relapse; no delusions, no paranoid
ideation
, - **Perceptual Disturbances:** None reported
- **Cognition:** Alert and oriented x4; attention/concentration fair (some distractibility)
- **Insight:** Fair (acknowledges addiction as a problem but ambivalent about specific changes)
- **Judgment:** Fair (recognizes relapse risk but struggles with coping)
- **Risk Assessment:** Denies SI, HI, or self-harm; expressed fear about relapse but no plan
**Screening Instruments (completed this session):**
| Instrument | Score | Interpretation |
|------------|-------|----------------|
| **CRAFFT** (applicable as history indicates adolescent onset) | N/A | History of early use (age 15) |
| **Addiction Severity Index (ASI)** | Referenced from intake | Highest severity in drug use,
family/social, psychiatric domains |
| **Clinical Opiate Withdrawal Scale (COWS)** | 4 | Minimal withdrawal (stable on methadone) |
**Relevant Laboratory Data (from chart review):**
| Test | Result | Date | Significance |
|------|--------|------|--------------|
| UDS | Negative for all substances | Yesterday | Confirms 4 weeks abstinence |
| Hepatitis C antibody | Positive | Intake | Requires medical follow-up |
| Liver enzymes | ALT 68, AST 72 | Intake | Mild elevation |
**Stage of Change Assessment (Prochaska & DiClemente):**
Based on session content and behavior, T.W. is assessed to be in the **Contemplation Stage** of
change . He acknowledges the problem and expresses ambivalence about change ("I'm not sure I can do
this").
---
### A: ASSESSMENT (Clinical Analysis & Diagnosis)
