Discharge/Termination Summary (Sports Psychology)

Client Name: [Client full name]

Date of Birth: [MM/DD/YYYY]

ID/MRN: [Identifier]

Encounter Type: Discharge/Termination Summary

Clinician: [Clinician name, credentials, role]

Service Context: [Setting, organization, sport]

Episode Dates: [First contact date] – [Last clinical contact date]

Date of Summary: [MM/DD/YYYY]

Service Modality: [in-person / telehealth / hybrid]

(Use neutral, behaviorally anchored language suitable for a third-party reader. If information is unavailable due to loss to follow-up or incomplete records, explicitly document what is unknown rather than inferring. Never document risk as absent unless it was assessed.)

Reason for Discharge

• Discharge type: [planned completion / unplanned / administrative]
• Termination initiated by: [client / clinician / mutual / third party]
• Primary reason: [goals met / plateau / referral or transfer / nonattendance / eligibility change / client preference / relocation / clinician departure / safety or role conflict / financial constraints]
• Pre-termination counseling: [provided / not provided] (If provided, summarize content briefly.)
• Alternatives offered: [Referrals and options discussed]

Lost to follow-up: [Not applicable / Client was lost to follow-up] (If lost to follow-up, document outreach attempts with dates and methods, information provided including crisis resources and re-engagement instructions, and what remains clinically unknown.)

Presenting Concerns and Formulation

Referral source: [Source and reason for referral]

Presenting concerns: [Performance concerns, mental health symptoms if applicable, adjustment issues, interpersonal/team concerns, identity transitions] (Summarize concerns at intake.)

Relevant context: [Injury status, season timing, role changes, major stressors] (Include only pertinent factors.)

Working formulation: [Key maintaining factors and intervention targets] (Use behaviorally anchored language.)

(If no formal intake occurred, state that and summarize what is known. Include diagnostic status only if operating within licensed mental health scope; for performance-only consulting, use a non-diagnostic frame.)

Episode Overview

Sessions: [Total number] sessions over [duration], [frequency/cadence]

Interventions: [Mental skills training such as imagery, self-talk, routines, attentional control; CBT/ACT skills; mindfulness; exposure; values work; stress management; sleep strategies; psychoeducation; communication skills; crisis/safety planning] (List only those used.)

Care coordination: [Coordination with sports medicine, primary care, psychiatry, coaching staff, athletic training] (Include only when consented.)

Barriers/facilitators: [Factors affecting engagement or outcomes] (Include only if significant.)

Attendance patterns: [Consistent / variable / pattern of no-shows or cancellations] (Include only if relevant to discharge.)

Goals and Progress

(Order goals by clinical severity first if safety concerns existed, then functional impairment, then performance optimization. If goals changed during care, note why and final status.)

Goal 1: [Goal description]

• Baseline: [Behaviorally anchored baseline status]
• Interventions: [Interventions applied to this goal]
• Progress evidence: [Client report, clinician observation, practice logs, competition performance, standardized measures]
• Attainment: [Met / Partially Met / Not Met / Deferred]

Goal 2: [Goal description]

• Baseline: [Behaviorally anchored baseline status]
• Interventions: [Interventions applied to this goal]
• Progress evidence: [Client report, clinician observation, logs, performance metrics, measures]
• Attainment: [Met / Partially Met / Not Met / Deferred]

(Add additional goals as needed.)

Standardized Outcome Measures

[Instrument name]: [Baseline score] → [Discharge score], [brief interpretation]. (Repeat for each measure used. Note limitations such as missing data or inconsistent administration. If no standardized measures were used, state: "No standardized outcome measures were administered; progress was evaluated using qualitative indicators and client-reported improvement.")

Status at Discharge

Functional status: [Current status across relevant domains: sport performance, mood, anxiety, sleep, energy, concentration, school/work functioning] (Include only domains relevant to this client.)

Coping capacity: [Client's ability to independently apply learned skills]

Risk Assessment at Discharge

(Include for episodes with mental health symptoms or any safety concerns. For performance-only cases without clinical symptoms, omit this subsection and include a brief clinical status statement above.)

• Suicidal ideation: [Present / Denied / Not assessed] (If present, describe frequency, intensity, plan, intent.)
• Self-harm: [Present / Denied / Not assessed]
• Other risks: [Violence, eating-related, substance-related, other] (Only if applicable.)
• Protective factors: [Supports, reasons for living, team/community resources, coping strengths]
• Overall risk level: [Low / Moderate / High]

Disposition: [Stable for discharge to self-management / Transitioning to higher level of care / Transferred to another provider / Unable to assess due to loss to follow-up]

Skills Learned and Maintenance Plan

(List skills learned grouped by domain. For each, note when to use it and practice plan. If disengaged early, distinguish skills introduced from skills mastered.)

Arousal regulation: [Skills learned] – Use during [triggers/contexts]. Practice [frequency] during [routine placement such as warm-up, cool-down, bedtime]. [Introduced / Practiced / Mastered]

Cognitive skills: [Self-talk, reframing skills learned] – Use during [triggers/contexts]. Practice [frequency and placement]. [Introduced / Practiced / Mastered]

Attentional control: [Skills learned] – Use during [triggers/contexts]. Practice [frequency and placement]. [Introduced / Practiced / Mastered]

Behavioral routines: [Pre-performance, reset, recovery routines] – Use during [contexts]. Practice [frequency and placement]. [Introduced / Practiced / Mastered]

Interpersonal skills: [Communication skills learned] – Use during [contexts]. Practice [frequency and placement]. [Introduced / Practiced / Mastered]

(Include only skill domains relevant to this client. Omit domains not addressed.)

Tracking method: [Practice log / app / coach check-ins / self-monitoring]

Relapse Prevention and Contingency Plan

Early warning signs: [Mood changes, avoidance, sleep disruption, training inconsistency, increased reassurance-seeking, decreased focus]

High-risk situations: [Injury setbacks, selection changes, major competitions, travel fatigue, interpersonal conflict, academic/work overload]

If-then plan: If [warning sign or trigger], then [specific action and coping strategy].

Escalation pathway: [Self-management] → [Support person/team resource] → [Clinician contact] → [Higher level of care or emergency services]

Crisis resources: [Safety plan summary and crisis contacts] (Include for any episode with safety risk history; for low-risk performance-only cases, include brief contingency contact information.)

Recommendations and Follow-up

Step-down level: [self-management / booster sessions / group support / team resources]

Referrals: [Provider name, discipline, rationale, information shared under authorization, appointment details] (Include each referral made.)

Re-engagement instructions: [How to re-engage services, recommended timing for check-in, what to do if symptoms recur]

Care coordination: [Third-party involvement with authorizations, scope, and summary of coordination] (Include only if applicable.)

Follow-up plan: [Scheduled check-ins / Client to initiate as needed / No follow-up clinically indicated]

Diagnoses

(Include only if operating within licensed mental health scope and diagnoses were assessed. Omit section entirely if no diagnostic work was performed.)

• [Primary diagnosis]: [ICD/DSM code]
• [Secondary diagnosis]: [ICD/DSM code] (If applicable.)

Focus of care: [performance / mental health / mixed]

Discharge status: [Completed treatment / Withdrew / Administrative discharge / Transferred]

Authentication

Clinician signature: [Electronic signature]

Credentials: [Credentials and title]

Date/time signed: [MM/DD/YYYY, HH:MM]

Supervisor co-signature: [Supervisor name, credentials] (Include only if trainee documentation requires co-signature.)