A therapy termination summary is the closing note in a client’s record: why they came, what treatment they had, how far they got, why therapy ended, and what happens next. Copy the free template, see a planned discharge after PTSD treatment and a file closed after a client stopped attending, and check what each part needs.
Blank therapy termination summary template
FreeTHERAPY TERMINATION SUMMARY Client: [Name or ID, date of birth] Clinician: [Name, credentials] Dates of service: [First session date to last session date] Sessions: [Number attended, cancelled, and missed; in person, video, or phone] Type of discharge: [Planned, client choice, no contact, referral out, or transfer] Date of summary: [Date written] REFERRAL AND DIAGNOSIS Reason for referral: [Who referred the client, and the presenting problem in a few lines] Diagnosis at intake: [Diagnosis and the main symptoms that supported it] Diagnosis at discharge: [Unchanged, revised, or criteria no longer met, and how you decided] TREATMENT PROVIDED Approach: [Therapy model by name and its main techniques] Course: [Session length and frequency, any step-down, and breaks in care] Other care: [Medication and prescriber, groups, other services, or none] Coordination: [Contact with other providers, with the client's consent, or none] OUTCOMES Measures: [Each measure by name, with its first and last scores and the sessions or dates] What the change means: [Response, remission, below a cutoff, no reliable change, or worse] Goal 1: [Goal as the plan states it; met, partly met, or not met; the evidence] Goal 2: [Goal as the plan states it; met, partly met, or not met; the evidence] Goal 3: [Goal as the plan states it; met, partly met, or not met; the evidence] Functioning: [Work or school, sleep, relationships, and self-care, at intake and now] REASON FOR TERMINATION Reason: [Goals met, client choice, no contact, needs beyond your scope, referral out, or clinician leaving] How it was decided: [When ending was first raised, and how the final date was set] Outreach: [For no contact: each call, message, and letter with its date, or not applicable] Client's view: [What the client said about ending and their progress, or not known] RISK AT DISCHARGE Last risk assessment: [Date, what you asked, and the answers] Risk and protective factors: [Factors that still apply, including access to means and substance use] Risk formulation: [Low, moderate, or high, with the reasons; for no contact, unknown since the last date] Safety plan: [Updated and given, not needed and why, or the step taken before closing] AFTERCARE Referrals: [Service, contact, and whether the client accepted, or none needed] Resources given: [988 by call or text, emergency services, local crisis or walk-in services, self-help] Relapse prevention: [Early warning signs, skills to keep using, and what to do if symptoms return] Information shared: [Who received a summary, and the consent on file, or none] Termination letter: [Date sent and how, or ending discussed in session only] PROGNOSIS AND RETURN Prognosis: [Good, fair, or guarded, with the reasons] Return to services: [How to come back, any wait, and whether a new intake applies; or where to go instead] File closed: [Date] Signed: [Clinician name, credentials, date] Reviewed by: [Supervisor or clinical director, credentials, date, where your organization requires it]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient therapy practice; planned discharge after 16 sessions of cognitive processing therapy
39-year-old man, a high school chemistry teacher. Dates of service: June 2 to October 13, 2026. 16 sessions attended, none missed: 12 weekly 60-minute sessions in person, then 4 sessions every 2 weeks. Type of discharge: planned, goals met. Summary written October 15, 2026.
Referred by his family physician 5 months after a night-time fire in his apartment building on December 19, 2025. He carried his 6-year-old daughter down 4 flights through smoke; an older neighbor on their floor died. At intake: nightmares on 4 nights a week, sleeping on the living room couch, avoiding the stairwell and the smell of the gas stove, checking the smoke alarms several times a night, and snapping at his family. Diagnosis at intake: posttraumatic stress disorder. Drinking 3 or 4 beers on 5 or 6 nights a week to get to sleep, AUDIT-C 5; no alcohol use disorder diagnosed, and drinking was added to the plan. Diagnosis at discharge: criteria reviewed in the interview at session 16; he no longer meets criteria for PTSD.
Cognitive processing therapy: a written impact statement, worksheets on stuck points, and practice between sessions. His main stuck point, “I should have knocked on her door,” fell from 90% belief at session 2 to 15% at session 12. Sessions 13 to 16 spaced to every 2 weeks, with graded practice on the stairwell and at the stove, and a written relapse prevention plan. His wife joined the last 20 minutes of session 14, with his consent, to learn the plan. No medication. With his consent, a progress update went to his family physician after session 8.
PCL-5, past-week version, before each session: 54 at session 1, 41 at session 6, 33 at session 10, 30 at session 12, and 24 at session 16. A 30-point drop, well past the 10 points often taken as a response, and below the 31 to 33 range often used to flag probable PTSD. PHQ-9 13 to 4. AUDIT-C 5 to 2. Goal 1, “sleep in my own bed through the night”: met; back in the bedroom since session 9, with 1 nightmare in the last 4 weeks. Goal 2, “take the stairs and cook again”: met; uses the stairwell daily and cooks on the gas stove most evenings. Goal 3, “talk to my daughter about the fire”: partly met; he answered her questions twice, but still changes the subject when she asks about the neighbor. Functioning: teaching full days; at intake he called in sick about once a week after bad nights. Checks the smoke alarms once a month.
Planned: goals 1 and 2 met, and the PCL-5 below its target of 33. Ending first raised at session 10; spacing to every 2 weeks agreed at session 12, and the final date set together at session 14. Client’s view: “I’m sleeping, I’m cooking, and I can walk past her door. I want to see if I can hold it on my own.” He chose to keep working on goal 3 at home with his wife, using the plan.
Asked directly at session 16: no thoughts of suicide or self-harm, now or at any point in treatment. No past attempts. No firearms at home. Alcohol down to 1 or 2 beers on Saturdays. Protective factors: his wife and daughter, work he values, and skills he now uses without prompting. Formulation: low risk. No safety plan was needed during treatment; the relapse prevention plan covers what to do if symptoms return.
Relapse prevention plan, written by him at session 15. Warning signs: sleeping on the couch, avoiding the stairwell, or nightmares on 2 or more nights a week for 2 weeks running. Steps: reread his impact statement and worksheets, restart a daily challenging-beliefs worksheet, and go back to stair practice; contact the practice if nothing changes within 2 weeks. The anniversary of the fire on December 19 is planned for: a quiet day with family and a call with his brother. Resources: 988, call or text, at any time; 911 or the nearest emergency department in an emergency. Shared: with his written consent, this summary to his family physician. Termination letter sent through the portal on October 14, with the plan attached.
Prognosis: good. A full response, gains held over 4 sessions spaced 2 weeks apart, skills used on his own, strong family support, and no substance or medical complications. The anniversary is the likeliest time for a dip. Return: one booster session booked for Tuesday, January 12, 2027, after the anniversary; welcome back at any time within 12 months without a new intake. File closed October 15, 2026; the booster is a single follow-up visit.
Group therapy practice, sessions by video; unplanned discharge after 5 sessions and no reply to outreach
33-year-old man, a restaurant kitchen manager. Dates of service: August 11 to September 8, 2026. 5 sessions attended by video, then 2 missed without notice, on September 15 and 22. Planned course: 12 to 16 weekly sessions. Type of discharge: no contact after outreach. Summary written October 14, 2026.
Self-referred for constant worry about money, his health, and his job for over a year, with trouble falling asleep, tension headaches, and irritability at work. Diagnosis at intake: generalized anxiety disorder, with insomnia as a target of treatment. Diagnosis at discharge: unchanged; no reassessment was possible.
CBT for generalized anxiety: psychoeducation, a worry log, scheduled worry time, and stimulus control for sleep. Sessions 4 and 5 began testing his “what if” predictions about money with small experiments. Other care: no medication. At intake he declined to have his family physician contacted.
GAD-7: 16 at session 1, 13 at session 3, and 11 at session 5, still in the moderate range. PHQ-9: 9 at session 1 and 7 at session 5. Sleep diary: asleep within 30 minutes on 2 nights a week at baseline, and on 4 nights by session 5. Goal 1, GAD-7 below 10: partly met; down 5 points. Goal 2, asleep within 30 minutes on 5 nights a week: partly met; 4 of 7 nights. Goal 3, “stop checking my bank app all day”: not met; work on it was due to start at session 6. Functioning at session 5: sleeping better and fewer headaches, but worry still took up “half my shift.”
No contact. He missed 2 sessions in a row without notice after session 5. Outreach: on September 15, a call and a voicemail giving only the clinician’s first name and the practice number; on September 22, a call and a portal message; on September 29, a letter by portal and by mail in a plain envelope, asking him to reply by October 13 and saying the file would close after that. No reply, and no mail returned. The consent form he signed at intake says a file may close after 2 missed sessions and 14 days with no reply. Possible factor, not confirmed: at session 5 he said his shifts were moving to evenings. Client’s view: not known.
Last assessed on September 8, at session 5: denied thoughts of suicide; item 9 of the PHQ-9 scored 0 at every session; no past attempts or self-harm; no firearms at home; 2 or 3 drinks after late shifts, unchanged since intake. Nothing in the record or the outreach pointed to a change. Formulation: low risk at last contact, and unknown since September 8. No grounds for a welfare check under the practice’s policy. Reviewed with the clinical director on October 14 before closing.
Resources listed in the September 29 letter: 988, call or text, at any time; 911 or the nearest emergency department in an emergency; his family physician, for sleep and anxiety, including medication options; a free, self-guided online CBT program for anxiety; and the practice’s evening video sessions. Relapse prevention: not reached in treatment; the letter reminded him of the worry log and the sleep routine. Shared: none; no consent on file to contact other providers.
Prognosis: fair. Early gains in 5 sessions and good engagement while he attended, but treatment stopped well short of the planned course, and symptoms are still moderate. Return: welcome to rebook. Within 90 days of closing, he resumes the same plan after a single update session; after that, a new intake. Evening video slots are open on Tuesdays and Thursdays. File closed October 14, 2026.
The facts of the episode of care: when it began and ended, how many sessions the client had, and what kind of discharge it was.
Avoid: Only the last session date. The span and the attendance tell the next clinician how much treatment the client actually had.
Why the client came, and what the diagnosis was at the start and at the end.
Avoid: Copying the intake diagnosis forward. If the client no longer meets criteria, or the diagnosis changed, say so and say how you know.
What the client received, named well enough that another clinician could pick up where you stopped.
Avoid: “Supportive therapy” or “various interventions.” Name the approach, so a returning client can restart what worked.
How far the client got: each measure from first to last score, every goal with its status, and daily functioning.
Avoid: “Client made good progress.” Give the numbers, and list the goals that weren’t met as well as those that were.
Why therapy ended, and how the decision was made.
Avoid: “Client terminated” or “noncompliant.” Record what happened, with dates, and leave out the verdict.
Where risk stood at the end. For a client who stopped coming, where it stood at last contact, and that it is unknown since.
Avoid: Closing a file with no risk statement. A reader months later needs to know what you knew at the end, and when you knew it.
What the client leaves with, who else was told, how you expect them to do, and how they can come back.
Avoid: “Return as needed.” Say how returning works: who to contact, any wait, and whether a new intake is needed.
Every summary needs the date of the last risk assessment and what it found. For a client who stopped coming, say that risk is unknown since that date, and record any step you took before closing.
“Improved” can’t be checked. Give each measure’s first and last score, and the status of every goal.
A goal missing from the summary reads as met, or forgotten. Mark it partly met or not met, and say what got in the way. A returning client starts there.
“Dropped out” or “poor motivation” says little, and reads badly if the client asks for their record. Write the missed dates and each attempt to reach them.
Without the referrals, the resources, and how to return, the next reader can’t tell what the client was told. Record all three, and the date the file closed.
Vero Scribe drafts the termination summary in your template from your dictation, or from the final session recorded with the client’s consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the dates, the number of sessions, and the type of discharge. Record the reason for referral, the diagnosis at intake and at discharge, and the treatment given. List each measure from first to last score, and each goal as met, partly met, or not met. Finish with the reason for ending, risk at discharge, referrals and resources, prognosis, and how the client can return. Write it soon after the last session or the closing date; many organizations set a deadline.
Yes. Termination summary, discharge summary, and closing summary all name the same note. Programs and counseling centers often say discharge; private practices often say termination. Whatever your organization calls it, it closes the episode of care in the record.
The letter goes to the client. It confirms the ending in plain words, names what they achieved, and lists support and how to come back. The summary stays in the record, with the diagnosis, the scores, the outreach dates, the risk formulation, and your reasoning. Most endings need both, and the summary notes when and how the letter went.
Record the last session, each missed session, and every attempt to reach the client, with dates. State the risk at last contact and that it is unknown since, and any step you took, such as calling the emergency contact when there was recent risk. Then give the outcomes so far, the resources you sent, the closing date, and how the client can return, following the policy in your informed consent.
Yes. Copy it, or download it as a Word or text file. No account needed.
One psychotherapy session: focus, interventions, client response, risk, and progress toward goals.
A CBT session in its own order: mood check, agenda, homework review, thought or exposure work, new homework, and feedback.
An EMDR session by phase: target, negative and positive cognitions, SUD and VOC, bilateral sets, closure, and reevaluation.
Data, Assessment, Plan: the three-part session note, with the line between facts and judgment made clear.
Goal, Intervention, Response, Plan: a progress note that opens with the treatment plan goal.
Intake, session, and closing notes drafted from your sessions, for you to review.
SOAP, DAP, and BIRP examples for the sessions before discharge.
How to score the PTSD Checklist and read change over treatment.
The plan a planned discharge hands over: warning signs and what to do.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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