THERAPY 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]