Discharge/Termination Summary (Pediatric Psychology)

Patient: [Patient full name; DOB; MRN; preferred name/pronouns if documented]

Episode Dates: [Start date] – [End date or date of last contact]

Setting: [outpatient / integrated primary care / inpatient consult / emergency department / intensive outpatient / partial hospital / school-based / other]

Termination Type: [planned discharge / transfer / patient or family-initiated / lost to follow-up / administrative discharge / clinician leaving practice / insurance or financial]

Participants in Care: [Patient; caregivers involved; interpreter use if applicable; key collateral contacts such as school personnel, PCP, subspecialists, care manager]

Reason for Discharge/Termination

[Primary reason for ending treatment and whether termination was mutually planned or unplanned] (If termination occurred against clinical advice, document that alternatives were discussed and referrals were provided.)

(If lost to follow-up: Document date of last attended session; each outreach attempt with dates and methods; response status; and whether current risk could be reassessed. If risk could not be reassessed, state this explicitly rather than inferring current status.)

Episode Overview

• Total contacts: [Number of sessions/contacts]
• Modality mix: [in-person / telehealth video / phone / collateral-only] (Briefly quantify.)
• Typical frequency: [weekly / biweekly / monthly / episodic]
• Service types provided: [evaluation / psychotherapy / parent training / group / consultation / biofeedback / care coordination / other]
• Attendance pattern: [Attended/cancelled/no-show pattern] (Include only if clinically relevant to outcomes; otherwise omit this line.)

Presenting Concerns and Referral Context

Referral source and question: [Referring provider/agency and explicit referral question] (If referral question was unclear, state this.)

Initial presentation and functional impact: [Initial symptoms/behaviors and severity; functional impact at home, school, with peers; medical adherence if relevant; pertinent family/system factors]

Diagnoses and Formulation

• [Diagnosis] [DSM/ICD code] (List each diagnosis on separate line.)
• [Ruled-out or provisional diagnoses] (Include only if they influenced treatment planning or referrals.)

Formulation: [Brief case formulation summarizing key maintaining factors, protective factors, and relevant contextual stressors. Anchor in documented assessment findings.]

Treatment Goals, Interventions, and Response

(Document each primary treatment target using the structure below; typically two to six targets.)

[Target 1: Patient-centered goal or target problem]

• Measurable indicator(s): [Symptom frequency, severity ratings, school attendance, adherence behaviors, or other measurable outcomes]
• Interventions: [Specific modalities used such as CBT, exposure/ERP, parent management training, DBT skills, motivational interviewing, relaxation training, sleep intervention, adherence intervention; include dose/intensity and note caregiver coaching, school collaboration, or interdisciplinary coordination when performed]
• Outcome status: [met / partially met / not met] [Brief explanation; if not met, document barriers without blaming language]
• Standardized measures: [Measure name: baseline score (date) → termination score (date) with clinical interpretation] (If measures were not administered, state this.)
• Patient/caregiver-reported benefit and remaining concerns: [Concise summary]

(Repeat structure above for each additional treatment target.)

Current functioning and remaining needs: [Brief integrative summary of functioning at discharge and what needs remain]

Risk Assessment and Safety Status

(This section is required and must reflect explicit assessment rather than inference.)

• Suicide/self-harm: [Current ideation, intent, plan, recent behaviors, access to means, protective factors; date of assessment]
• Violence risk: [Ideation, intent, plan, recent behaviors, access to weapons, triggers, protective factors] (Include if applicable.)
• Abuse/neglect safety concerns: [Concerns identified; mandated reporting actions; coordination with protective services] (Include if applicable.)
• Other pediatric safety considerations: [Severe dysregulation, elopement risk, substance use, medical nonadherence, eating disorder medical risk] (Include domains relevant to this patient.)
• Disposition and current risk level: [low / moderate / high / unable to reassess] [What this means operationally, such as appropriate for outpatient management versus requires higher level of care]

Safety planning: [Safety plan completed/updated at termination; who received copies; lethal means counseling provided; crisis instructions given] (Include if suicide/self-harm risk present.)

(If lost to follow-up or no contact at termination: State explicitly that risk could not be reassessed; provide last assessed risk status with date. Do not state low risk without current assessment.)

Relapse Prevention and Maintenance

(For consultative-only episodes without ongoing conditions, abbreviate to key skills reviewed and criteria for re-referral. Omit section entirely if not applicable.)

• Early warning signs: [Patient-specific signs of symptom return or escalation]
• Effective skills and strategies: [Concrete coping skills and routines that worked during treatment]
• Caregiver/environmental supports: [Routines, reinforcement plans, sleep hygiene, school accommodations, monitoring strategies]
• Stepwise plan for symptom return: [Self-management steps → contact supports → contact providers → crisis services]
• Booster sessions: [recommended / not recommended] [Timeframe if applicable]

Follow-up and Referrals

• Next level of care and timeframe: [Outpatient therapy, psychiatry evaluation, IOP, school-based counseling, etc.; specify urgency]
• Scheduled appointments: [Provider/clinic, date/time, modality] (Include only appointments actually scheduled.)
• Recommended referrals: [Referral type and how to access] (If acceptance is unknown, document as recommended rather than confirmed.)
• Care coordination: [PCP, subspecialist, or care management coordination points]
• School-related steps: [Recommended accommodations; permissions needed for information exchange] (Include if applicable.)

Medications

(Include only if relevant to continuity or safety. Omit section entirely if not applicable.)

• Current psychotropic medications and prescriber: [Medication, dose, frequency; prescriber]
• Significant medication changes during episode: [Changes that affected symptoms or functioning]
• Coordination with prescribers: [Summary of communications and shared plans]

Materials and Records

(Include only if materials were provided or special record-sharing occurred. Omit section entirely if not applicable.)

• Copies provided to patient/family: [Safety plan, skill handouts, crisis resources, behavior plans]
• Summary sent to referring providers: [Yes/No; recipients and date]
• Confidentiality constraints: [Adolescent confidentiality provisions or state-specific minor consent laws affecting record sharing]

Author: [Name, credentials] | Date: [Date of signature]

Supervising clinician: [Name, credentials] | Date: [Date of attestation] (Include only if author is a trainee requiring supervision.)