Creative Arts Therapy Discharge Summary

Patient: [Full name; DOB; MRN; pronouns; preferred name if collected]

Program/Setting: Creative Arts Therapy; [level of care: outpatient / inpatient / partial hospital / residential / IOP / school-based]; Discharge Summary

Episode Dates: [Episode start date]; [Discharge date]; [Last contact date]; [Total sessions]; [Approximate frequency]

Therapist: [Therapist name, credentials, license]

Reason for Discharge

[Discharge type: planned / unplanned] — [Primary reason: goals met / clinical plateau / patient request / relocation / level-of-care change / nonattendance / insurance change / other]. [Disposition: next setting or provider; follow-up status: scheduled / recommended only / declined]

Episode Overview

Referral: [Referral source and reason for referral]

Patient goals at admission: [Patient's stated goals at start of care] (Use patient's own terms when available.)

Diagnoses/problem list: [Relevant diagnoses or problems addressed this episode]

Baseline functioning: [Primary impairments at admission affecting emotion regulation, behavior, relationships, school/work, ADLs]

Strengths and protective factors: [Personal strengths, supports, interests, cultural/spiritual resources identified at admission]

Treatment plan and structure:

• Goals: [Primary treatment goals with measurable elements]
• Frequency: [Planned frequency] vs. [Actual attendance pattern]
• Modalities: [art / music / dance-movement / drama / expressive arts]; [individual / group / family]
• Coordination: [Interdisciplinary teams, care conferences, collateral contacts] (Include only if applicable.)

Course of Treatment

(Include only modalities actually utilized. Document what was done and how the patient responded. Avoid detailed reproduction of private creative content unless necessary for safety or continuity.)

[Modality: Art Therapy / Music Therapy / Dance-Movement Therapy / Drama Therapy / Expressive Arts]

• Format: [individual / group / family]; [setting and co-facilitation if applicable]
• Core techniques: [Specific intervention techniques employed]
• Clinical targets: [e.g., emotion regulation, trauma processing, social skills, self-concept, sensorimotor grounding, distress tolerance]
• Engagement and response: [Attendance/participation patterns; level of engagement; patient-reported experience; observed affect shifts; skill acquisition or generalization] (Anchor to observable behaviors.)
• Notable events or modifications: [Significant clinical events; adaptations; rationale for changes] (Include only if applicable.)

(Repeat modality subsection for each additional modality used.)

Progress Toward Goals

(Prioritize highest-risk or highest-priority problems first.)

Goal [#]: [Goal description]

• Status: [Met / Partially met / Not met / Unable to assess]
• Evidence: [Behavioral examples; patient self-report; standardized measures with scores and dates; functional changes]
• Remaining barriers: [Symptoms; environmental factors; skills not yet generalized; engagement issues] (Omit if goal met.)
• Formulation: [Why progress occurred or did not] (Link to interventions, engagement, context.)

(Repeat goal subsection for each treatment goal.)

Current Clinical Status

• Mental/behavioral status: [Appearance; mood/affect; thought process/content; insight/judgment as relevant]
• Functional status: [School/work participation; relationships; independent use of coping skills and arts-based strategies]
• Clinical acuity: [stable / improving / worsening] — [Brief explanation anchored to objective observations]

Risk and Safety Status

• Risk domains assessed: [suicide ideation/behavior / non-suicidal self-injury / violence risk / abuse-neglect concerns / substance-related risk]
• Screening tools: [Tool name, date, score] (Include only if completed.)
• Current risk level: [Low / Moderate / High] — [Rationale citing current ideation, plan, intent, past behavior, protective factors, supports]
• Risk mitigation at discharge: Safety plan [created / updated / reviewed / deferred (reason)]; Lethal means counseling [completed / not indicated / deferred (reason)]; [Monitoring recommendations]
• Mandated reporting: [Report filed: yes/no; date; agency; brief rationale] (Include only if applicable.)

Safety Plan

(Include if safety plan was created or updated this episode.)

• Warning signs: [Personal warning signs identified by patient]
• Internal coping strategies: [Self-guided strategies patient can use alone]
• People/places for distraction: [Social contacts and locations for support]
• Support persons: [Names/roles and contact information]
• Crisis resources: [Provider contacts; crisis lines; local emergency services]
• Means safety steps: [Measures taken or planned to reduce access to lethal means]
• Plan location: [Where safety plan is stored and how patient will access it]

Relapse Prevention

(Include when clinically indicated; omit if not applicable.)

Triggers and warning signs: [Likely relapse triggers and early warning signs]

Maintenance strategies: [Personalized coping strategies including arts-based practices for independent use]

Re-engagement criteria: [Clear indicators for when to return to care or seek higher level of care, and steps to take]

Aftercare and Follow-up

• Referrals: [Service type; provider/agency; date initiated; scheduled/pending/declined; ROI status]
• Warm handoff: [Completed: yes/no]; Records sent: [treatment summary / safety plan / other]; [Date and method]
• Follow-up appointments: [Scheduled date/time/provider] or [Recommended frequency if not yet scheduled]
• Understanding confirmed: [Patient/caregiver verbalized understanding of aftercare plan: yes/no]

Creative Works Disposition

(Omit if no creative works or media were created or retained.)

• Physical artworks: [returned to patient / retained in record / stored / destroyed] — [Date; rationale if not returned]
• Digital media: [Storage location; access controls; retention period] (Confirm no identifying information about other group members is included.)
• Consent for use beyond treatment: [Consented (scope/duration) / declined / not applicable]

Author: [Therapist name, credentials, license] — [Date]

(If discharge summary is based on record review due to unplanned termination or no final visit, state: "Summary completed via record review; last documented contact [date].")