Behavioral Health Discharge Summary

Patient Name: [Full legal name]

DOB: [MM/DD/YYYY]   MRN: [Medical record number]

Program/Level of Care: [Outpatient / IOP / PHP / Other]

Admission Date: [MM/DD/YYYY]   Discharge Date: [MM/DD/YYYY]   Last Clinical Contact: [MM/DD/YYYY] (Only include if different from discharge date)

Primary Clinician: [Name, credentials]   Prescribing Clinician: [Name, credentials] (Only include if applicable)

Referral Source: [Self / Family / PCP / ED / Court / Other]

(Use concise bullets for lists and short paragraphs for narrative. Attribute information sources with "Per patient," "Observed in session," or "Per collateral." Omit sections that do not apply. Focus on clinically actionable information for continuity of care.)

Reason for Discharge & Disposition

Reason for Discharge: [Goals met / Step-down / Step-up to higher level of care / Patient request / Nonadherence or nonattendance / Administrative discharge / Insurance or eligibility / Lost to follow-up / Other]

Disposition: [Home/self-care / Transferred to specific program or provider / Referred to specific service / Unknown]

(If discharge is against clinical advice, include the following.)

• Clinician recommendation: [Recommended level of care and rationale]
• Patient stated reason: [Summary if offered]
• Capacity assessment: [Has capacity / Lacks capacity / Not assessed] — [Brief rationale]
• Outreach and safety actions taken: [Attempts made, safety planning completed, crisis resources provided]

Diagnoses at Discharge

(List in problem-list format, highest priority first. Include specifiers. Include medical conditions only if they materially affect behavioral health care. Note working diagnoses with supporting evidence and what remains to clarify.)

• [Primary behavioral health diagnosis with specifiers] — [Confirmed / Working]
• [Secondary behavioral health diagnosis if applicable]
• [Relevant medical condition and its impact on BH care] (Only include if applicable)

Presenting Problem & Baseline

[Brief 4–8 sentence narrative summarizing chief concerns at entry, initial risk status if it influenced level-of-care selection, baseline functional impairments, and key strengths/protective factors. Include baseline rating scale scores if used (e.g., PHQ-9, GAD-7).]

Course of Treatment

• Services provided: [Individual therapy modality (e.g., CBT, DBT skills, MI); group therapy; family/couples sessions; case management; peer support; medication management] — [Approximate sessions attended / offered]
• Attendance and barriers: [Consistent / Variable / Poor] — [Key barriers if any]
• Key clinical events: (Only include events that occurred)
  • [Safety events: suicidal crises, self-harm, hospitalizations, ED visits, overdose] — [Dates and brief summary]
  • [Major medication changes] — [Rationale and response]
  • [Significant psychosocial changes impacting risk: housing, legal, relationships, supports]

(If no major events: No significant safety events or major clinical changes during the episode.)

Outcomes & Response to Treatment

(For each treatment goal, indicate status and brief evidence. Use "Unable to Assess" if lost to follow-up.)

• Goal 1: [Goal description] — [Achieved / Partially Achieved / Not Achieved / Unable to Assess]
  • [Evidence: symptom change, functional change, measure change, or skill use]
• Goal 2: [Goal description] — [Achieved / Partially Achieved / Not Achieved / Unable to Assess]
  • [Evidence]

Current status at discharge: [Brief summary of symptom burden, functional status, and remaining needs]

Patient perspective: [Per patient: satisfaction with progress, preferences for ongoing care]

Discharge Risk Status

(State risk domains explicitly with current level and rationale. Do not imply risk; state it directly.)

Suicide/Self-Harm Risk

• Current ideation: [None / Passive / Active]
• Plan: [None / Vague / Specific]
• Intent: [Denied / Ambivalent / Present]
• Recent attempts or self-harm during episode: [No / Yes with dates and details]
• Protective factors: [Key protective factors]
• Risk level: [Low / Moderate / High] — [Brief rationale]
• Means safety counseling: [Completed / Reinforced / Declined / Not indicated] — [Details of means safety steps if applicable]

Violence/Homicide Risk

(Only include if relevant to this patient.)

• Current ideation/threats: [None / Conditional / Specific]
• History and risk factors: [Brief relevant history]
• Risk level: [Low / Moderate / High] — [Brief rationale]
• Duty-to-protect actions: [Notifications, safety steps taken] (Only include if applicable)

Substance Relapse/Overdose Risk

(Only include if relevant to this patient.)

• Substances of concern: [List]
• Last known use: [Date or timeframe]
• Relapse triggers: [Key triggers identified]
• Overdose history and risk factors: [Summary]
• Harm reduction measures: [Naloxone provided / Safer-use counseling / Fentanyl test strips / Other]
• Risk level: [Low / Moderate / High] — [Brief rationale]

Other risk domains: [Grave disability / Abuse or neglect concerns / Other] — [Assessment and actions taken] (Only include if relevant)

(If lost to follow-up: Document risk status at last contact with date, note inability to reassess, and list outreach attempts.)

Safety & Crisis Plan

(Include when any meaningful risk exists; otherwise omit this section.)

• Warning signs: [Thoughts, feelings, behaviors indicating escalation]
• Internal coping strategies: [Skills and activities]
• Social supports: [Names/relationships and contact methods]
• Professional contacts: [Treating clinic; next provider; business hours contact]
• 24/7 crisis resources: [Local crisis line; 988; mobile crisis; ED for emergencies]
• Means safety steps: [Lethal means restriction plan if applicable]
• Plan distribution: [Where plan is stored; who has a copy]

Relapse prevention component: (Only include for substance use concerns)

• Personal triggers: [List]
• Early relapse indicators: [List]
• Effective strategies: [Skills and approaches that worked]
• Recovery supports: [Meetings, sponsors, peers, family]
• Step-up plan: [How to access higher level of care if symptoms recur]

Medications at Discharge

(Include if the program prescribed, adjusted, or monitored medications. If not, state medications are managed externally or omit this section.)

Source of medication list: [Patient report / Pharmacy verification / EHR / External prescriber records]

• [Medication name] — [Dose] [Route] [Schedule] — [Indication]
• [Medication name] — [Dose] [Route] [Schedule] — [Indication]

Changes during episode: [Medication starts, stops, or dose adjustments with rationale and response]

Adherence: [Good / Fair / Poor] — [Basis for estimate]

Side effects: [Notable side effects or "none reported"]

(If medications managed externally: Medications managed by [external prescriber name/clinic]. Recommend verification at next visit.)

Aftercare Plan & Follow-Up

Scheduled appointments:

• [Provider name, role] — [Purpose] — [Date/Time] — [Contact info]

Follow-up to be scheduled: [Who to call, recommended timeframe, contact info]

Referrals placed: [Therapy / Psychiatry / SUD treatment / Primary care / Community supports / Social services] — [Date sent, contact details]

Care transition communication: [Discharge summary sent to receiving provider on date via method; warm handoff completed/not completed]

Declined referrals: [Education provided and crisis resources given] (Only include if patient declined)

Patient discharge guidance:

• Warning signs to watch for: [Personalized warning signs]
• Continue: [Skills, routines, support groups to maintain]
• When and how to seek help: [Business hours contact; after-hours resources; 988; ED for emergencies]
• Medication instructions: [Continue/change instructions; do not stop abruptly warnings if applicable; contact for questions] (Only include if applicable)

Author & Authentication

Author: [Name]

Credentials/Role: [Credentials and role]

Date/Time: [MM/DD/YYYY HH:MM]

Contact: [Clinic phone for receiving clinicians]

Supervising Clinician: [Name, credentials] — [Signature/Date] (Only include if supervision applies)