Termination/Discharge Summary (Grief Counseling)

Patient and Episode Information

• Patient Name: [Patient full name]
• DOB: [Date of birth]
• MRN: [Medical record number]
• Episode Start Date: [Start date]
• Episode End Date: [End date]
• Date of Last Session: [Date]
• Total Sessions Attended: [Number]
• Clinician: [Clinician name, credentials]
• Service Location: [Clinic/site or telehealth jurisdiction]

(Write for a future treating clinician and for audit readability. Prefer behavioral, observable, time-anchored descriptions over global judgments. If information is unavailable due to unplanned termination, explicitly note the limitation and the date of last known information rather than leaving sections blank.)

Discharge Disposition

• Type: [planned completion / unplanned termination / transfer of care / administrative discharge]
• Initiated by: [patient / clinician / mutual / other]
• Outreach attempts: [Dates, methods, and outcomes of contact attempts] (Include only for unplanned terminations.)
• Transfer details: [Receiving provider/service, reason for transfer, warm handoff status] (Include only if transferring care.)
• Effective date of disposition: [Date]

Presenting Problem and Loss Context

[Referral source and reason for seeking treatment; relationship to deceased and timeframe of loss; contextual factors affecting grief; primary grief symptoms at intake; baseline functioning in work, relationships, and daily activities] (Use minimum necessary detail and avoid unnecessary third-party identifiers.)

Diagnosis at Intake: [Formal diagnosis with code, or state "Supportive bereavement counseling without mental disorder diagnosis"]

Course of Treatment

• Treatment frame: [Planned vs actual session frequency; dates; changes in intensity over time]
• Modality: [individual / family / group / combined]
• Interventions utilized: [List interventions actually used, such as psychoeducation, behavioral activation, cognitive restructuring, meaning reconstruction, exposure to avoided reminders, anniversary planning, trauma-focused work, family involvement, sleep/routine stabilization]
• Significant clinical events: [Risk escalations, hospitalizations, major anniversaries, medication changes, functional milestones with dates] (Omit if none.)
• Engagement and barriers: [Attendance patterns, ambivalence, logistical obstacles] (Omit if none.)

Treatment Goals and Outcomes

(List goals established at intake. For each, indicate status with brief evidence. Note strategies that were most helpful and remaining challenges.)

• Goal 1: [Goal description]
  • Status: [met / partially met / not met / unable to assess]
  • Evidence: [Patient report, clinician observation, or functional milestones with timeframe]
  • Effective strategies: [Interventions or skills linked to progress]
  • Remaining challenges: [Residual symptoms or obstacles] (Omit if goal fully met.)
• Goal 2: [Goal description]
  • Status: [met / partially met / not met / unable to assess]
  • Evidence: [Patient report, clinician observation, or functional milestones with timeframe]
  • Effective strategies: [Interventions or skills linked to progress]
  • Remaining challenges: [Residual symptoms or obstacles] (Omit if goal fully met.)
• (Add additional goals as needed.)

Standardized measures: [Measure name, baseline score with date, discharge score with date] (Include only if administered.)

Current Status at Discharge

(For unplanned terminations, retitle this section "Last Known Status" and include date of last clinical contact. Explicitly state what could not be assessed.)

• Date of status: [Date]
• Grief symptoms compared to baseline: [Current symptom presentation across domains such as yearning, intrusion, avoidance, guilt, meaning, social connection]
• Functioning: [Work/school, relationships, daily activities]
• Current stressors: [List]
• Current supports: [List]
• Discharge diagnosis: [Diagnosis with code, or "No mental disorder diagnosis—bereavement counseling" with brief rationale]
• Mental status: [Relevant findings] (Include only if clinically significant abnormalities present.)

Risk Assessment and Safety Planning

(Do not use blanket statements. Specify what was assessed and what was found.)

• Suicide risk assessment:
  • Ideation: [none / passive / active]
  • Plan/intent: [present / absent / unable to assess]
  • Access to means: [Details] (If relevant.)
  • Recent self-harm behaviors: [Details or "Denied"]
  • Key risk factors: [List]
  • Protective factors: [List]
  • Clinical risk judgment: [Risk level per organization terminology]
• Violence risk or abuse/neglect concerns: [Findings and actions taken] (Include only if assessed.)
• Safety plan: [exists / not indicated / declined], last reviewed [Date], stored in [Location]
• Safety plan elements:
  • Warning signs: [Patient-specific early signals]
  • Coping strategies: [Internal and external coping skills]
  • Support contacts: [Names/roles and contact methods]
  • Crisis resources provided: [Resources appropriate to locale]
  • Lethal means counseling: [completed / not applicable / declined] (Include details of means restriction if applicable.)

Relapse Prevention Plan

• Early warning signs of deterioration: [Patient-specific signs such as sleep disruption, increased avoidance, isolation, substance use, anniversary-related distress]
• Coping skills found most effective: [Skills and when/how to apply them]
• Anniversary/holiday plan: [Anticipated triggers and planned responses]
• Re-entry plan if symptoms worsen:
  • Self-management steps: [Stepwise plan]
  • When to contact supports: [Criteria and contacts]
  • When to contact clinic: [Criteria and contact details]
  • When to use crisis services: [Criteria and resources]

Referrals and Follow-Up

• Follow-up recommendation: [treatment complete / continue therapy / psychiatric evaluation / transfer of care]
• Receiving provider/service: [Name, contact information, appointment date/time, information shared] (Include only if transferring care.)
• Referrals provided: [Referral type, accepted/declined, date] (Include only if referrals were made.)
• How to access services in the future: [Contact instructions and eligibility notes]
• Crisis contact information: [Local crisis line, 988 Lifeline, 911/ED, clinic after-hours as appropriate]

Medications

(Include this section only if psychotropic medications are relevant to this episode. Omit entirely if not applicable.)

• Current psychotropic medications: [Name, dose, frequency]
• Prescriber: [Name, specialty] (If known.)
• Recent changes during episode: [Medication changes with dates] (If any.)