Outpatient Psychotherapy/Counseling Discharge/Termination Summary

Patient name: [Patient full name]

DOB: [Date of birth]

MRN/Chart ID: [Medical record number or chart ID]

Pronouns: [Documented pronouns] (Only include if documented)

Clinic/Program: [Clinic or program name]

Authoring clinician: [Clinician name, credentials]

Episode start date: [Date]

Episode end date / last contact: [Episode end date or last patient contact date if terminated without a final session]

Total sessions attended: [Number]

Reason for Discharge

Discharge type: [planned completion/goals met / mutual agreement to end or step down / transfer of care / step up to higher level of care / patient-requested termination / loss to follow-up / administrative discharge / other]

[Rationale describing who initiated termination and primary reason] (1–3 sentences)

(For unplanned terminations only) Last attended session: [Date]

(For unplanned terminations only) Reason for termination: [Known reason or state unknown]

• (For unplanned terminations only) Outreach attempts: [Date] — [Method] — [Outcome]
• (Repeat for each outreach attempt)

Presenting Problem

[Narrative summary of referral source and context, primary symptoms and concerns at entry, functional impacts, and patient-stated goals. Include initial diagnoses if assigned and baseline standardized measure scores with dates if used.] (3–6 sentences; keep clinically focused)

Diagnoses at Discharge

• Primary diagnosis: [Diagnosis (ICD-10/DSM code)] — [active / improved / in remission / resolved / rule-out]
• Secondary diagnosis: [Diagnosis (code)] — [active / improved / in remission / resolved / rule-out] (Include additional diagnoses as needed)

(If no formal diagnosis was established) [No formal diagnosis established; brief description of presenting symptoms and focus of care]

• Relevant comorbidities: [Medical or psychiatric comorbidities] (Only include if relevant)
• Psychosocial factors: [Key social determinants, stressors, or contextual factors] (Only include if relevant)
• Protective factors: [Identified strengths, supports, or resources] (Only include if relevant)

Treatment Summary

[High-level summary of treatment modalities used, primary clinical targets addressed, and key skills taught or practiced] (Avoid verbatim session content or granular process details)

Goals and Outcomes

• Goal: [Patient-centered goal statement]

  Baseline: [Brief baseline description and/or measures with dates]

  Interventions: [Core interventions and skills applied]

  Outcome: [met / partially met / not met] — [Brief supporting evidence]

• (Repeat goal block as needed)

Overall response pattern: [improved / partially improved / no meaningful change / worsened / mixed]

Notable barriers/facilitators: [Factors that influenced treatment course] (Only include if clinically significant)

Current Clinical Status

[Current functioning summary including living situation, occupational/academic status, relationships/supports, and relevant self-care or behavioral patterns] (If discharge was unplanned, state the date of last assessment and summarize that status instead)

Mental status (brief): [Appearance and behavior]; [Mood and affect]; [Thought process and content]; [Cognitive or perceptual observations]; [Insight/judgment] (Include only elements assessed)

Risk and Safety Status

(If no suicide, self-harm, or violence risk history exists and none is present at discharge, a brief attestation is sufficient)

• Suicide risk: [History during episode and current status, including ideation/behavior and access to lethal means if clinically indicated]
• Self-harm: [History during episode and current status]
• Homicide/violence risk: [Current status and pertinent history]
• Safety plan: [exists / not indicated] — [Reviewed/updated date and location in chart]
• Crisis resources provided: [Resources shared verbally and/or in writing]
• (If risk elevated or uncertain) Mitigation steps: [Specific steps taken, consultations, means restriction counseling, follow-up arrangements]
• (If lost to follow-up) Risk status: Cannot be reassessed due to lack of contact. [Document crisis resources provided in written outreach communications]

Medications

(Include this section if psychotropic medications were prescribed/managed by this clinic, materially affected therapy, or are needed for transfer continuity)

• [Medication name] — [Dose, route, frequency] — [Indication] — [Prescriber]
• (Repeat for each medication)

Adherence/side effects: [Patient-reported adherence and notable side effects]

Refills/follow-up: [Refills provided and recommended follow-up with prescriber or PCP]

(If no medications managed) No psychotropic medications were managed by this clinic during this episode.

Recommendations and Aftercare

[Ongoing clinical needs including active symptoms/impairments, skills requiring reinforcement, and unresolved issues]

• Level of care and frequency: [Recommended level and cadence of care]
• Modality recommendations: [Recommended treatment modalities and focus areas]
• Referrals made: [Provider/clinic name] — [Reason] — [Patient accepted/declined] — [Records sent: yes/no]
• Follow-up appointments: [Scheduled date/time/location or instructions for scheduling]
• Relapse prevention: [Warning signs/triggers]; [Effective coping strategies]; [Support network]; [Criteria for re-entering care]
• Patient preferences and agreement: [Patient preferences and whether they agreed with or declined recommendations; if declined, note education provided and alternatives offered]

Signature

Clinician signature: [Name, credentials] — [Date]

(If documentation completed after episode end date) Authorship date: [Date note authored]