Discharge/Termination Summary (Play Therapy)

Client: [Client name and identifiers]

Date of Birth: [DOB]   Age: [Age]

Episode Dates: [Start date] through [End date]

Total Sessions: [Number] child; [Number] caregiver; [Number] family

Author: [Clinician name and credentials]

(This is an end-of-episode summary for continuity of care and safe transitions. Summarize themes and outcomes rather than session-by-session detail. Attribute information to sources. Use developmentally appropriate language. For missing information, use: Not assessed, Unknown, Unable to assess, or Not applicable. Safety-related items must not be left blank.)

Reason for Termination

[Primary reason for termination]. [Planned / Unplanned] termination initiated by [caregiver / clinician / mutual agreement / system / insurance / other]. Pre-termination planning [occurred / did not occur]. Referrals were [offered and accepted / offered and declined / offered and pending / not indicated]. (Two to four sentences.)

Presenting Problems at Intake

[Referral source and chief concern in caregiver language]. [Primary symptoms and behaviors with functional impact across home, school, peers, and emotional regulation]. [Relevant psychosocial and developmental context]. [Baseline risk concerns if present]. (One concise paragraph; include only what is needed to understand treatment and outcomes.)

Diagnoses

• [Diagnosis with ICD code if used]
• (Add or remove bullets as appropriate. If diagnosis deferred or not assigned, state reason.)

Changes from intake: [Added, removed, or ruled-out diagnoses with brief rationale, or "No changes from intake"]

Clinical formulation: [Two to three sentences integrating maintaining factors, child and caregiver strengths, and how these informed the play therapy approach]

Treatment Summary

• Setting and intensity: [Setting]; [Frequency and session duration]; [Changes over time if applicable]
• Participants: [Child-only, caregiver, family, and/or sibling sessions with approximate counts or proportions]
• Play therapy modality: [Child-centered / Directive / Integrative / Other]
• Adjunctive interventions: [Parent coaching, CBT skills, trauma-focused components, art-based interventions, other as applicable]
• Key intervention targets: [Emotion regulation, coping skills, parent-child relationship, behavior, social skills, grief processing, other]
• Barriers and modifications: [Barriers encountered and how the plan was adjusted]
• Care coordination: [Collaborating providers and systems, or "None"]

Progress Toward Goals

(List highest-risk or highest-impairment goals first. Include standardized measure names, dates, and scores when available. If measures were not used, rely on qualitative evidence.)

Goal 1: [Behaviorally anchored goal statement]

Status: [Met / Partially Met / Not Met / Unable to Assess]

Evidence: [Caregiver report, teacher/school report, clinician observation, and/or standardized measures with sources cited]

Goal 2: [Behaviorally anchored goal statement]

Status: [Met / Partially Met / Not Met / Unable to Assess]

Evidence: [Supporting evidence with sources cited]

(Add additional goals as needed.)

Discharge Status

• Home behavior and routines: [Current functioning and caregiver management]
• Emotional regulation: [Current capacity, coping skills used, remaining triggers]
• Peer functioning: [Social interactions and play skills]
• School functioning: [Attendance, engagement, behavior, learning]
• Skills consolidated: [Key skills the child demonstrates]
• Supports needed to maintain gains: [Caregiver strategies, accommodations, ongoing services]
• Remaining vulnerabilities: [Triggers, behaviors, or contexts to monitor]
• Prognosis: [Favorable / Guarded / Uncertain] with brief rationale

Risk and Safety Summary

(If no risk concerns were identified during the episode, state: "No suicide/self-harm, aggression/violence, or abuse/neglect concerns were identified during this episode." and omit the detailed bullets below.)

• Suicide/Self-harm risk: [Current status]; [Low / Moderate / High] with rationale
• Aggression/Violence risk: [Current status]; [Low / Moderate / High] with rationale
• Abuse/Neglect concerns: [Current status and any mandated reporting actions taken]
• Safety plan: [Exists and was reviewed at discharge / Not applicable]
• Overall risk level: [Low / Moderate / High] with brief rationale

Aftercare Plan

• Recommended level of care: [Level of care and type of services]
• Referrals: [Provider/agency, purpose, and status for each referral]
• Re-engagement triggers: [Specific symptoms, thresholds, or functional declines prompting re-contact]
• Crisis resources: [Per organizational policy]

Caregiver Recommendations

• Home strategies to continue: [Emotion coaching, limit-setting, reinforcement, coping skill practice]
• Recommended routines: [Schedules, transitions, environmental supports]
• Resources: [Books, classes, parent programs, support groups as appropriate]

School Recommendations

(Include only if school concerns were part of treatment and clinician is authorized to provide recommendations; otherwise omit this section.)

• Functional supports: [Transitions, schedules, calm-down space, breaks, seating]
• Communication plan: [School-home updates, point-person, frequency]
• Safety supports: [Crisis protocol, supervision parameters if relevant]

Termination Process

[How termination was introduced and planned]. [Closure activities at a high level]. [Child and caregiver responses]. [Concerns relevant to relapse risk or continuity]. (Three to five sentences.)

Signature

Clinician Signature: [Name, credentials]   Date: [Date]