Therapy Discharge Summary (CBT Course of Care)

Patient: [Patient name per organizational policy]

DOB: [Date of birth]

MRN: [Medical record number] (If not used, omit this line.)

Clinician: [Clinician name, degree(s), license(s)]

Service Location: [Clinic/site name]

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

Last Session Date: [Date]

Sessions Completed: [Number attended]

Sessions Missed/Cancelled: [Number]

Session Frequency: [Typical cadence, e.g., weekly → biweekly]

Referral Source: [Self / PCP / Psychiatry / Other] (Omit if not applicable.)

Care Team: [PCP, psychiatrist, other involved providers with names and roles] (Omit if none.)

Reason for Discharge

[Primary discharge reason: treatment goals met / partial completion with booster plan / transfer to another provider / step-up to higher level of care / administrative discharge / lost to follow-up / patient request]. [Planned / Unplanned] discharge. Patient [participated / did not participate / partially participated] in discharge planning. [If transfer or step-up: receiving provider/program]. [If unplanned or lost to follow-up: outreach attempts with dates and methods]. [Limitations on final assessment, e.g., "Final symptom measures not obtained due to disengagement."]

Presenting Problem & Baseline Formulation

[Presenting concerns prompting care, including symptom domains and duration]. [Baseline severity with dates and supporting data]. [Functional impact: work/school, relationships, sleep, avoidance patterns]. [CBT formulation: key maintaining factors (avoidance, safety behaviors, rumination, cognitive distortions), relevant triggers]. [Strengths and protective factors]. [Diagnostic impression at intake with DSM/ICD code(s); label diagnostic uncertainty if present]. (Avoid detailed trauma narratives; use high-level descriptors sufficient for continuity.)

Course of Treatment

[Summarize CBT interventions delivered as a narrative paragraph or brief list. Cover as applicable: orientation to CBT model and goal-setting; psychoeducation on disorder-specific model; cognitive interventions (thought monitoring, cognitive restructuring, core belief work) with targets; behavioral interventions (behavioral activation, graded tasks, skills practice); exposure-based interventions if used (in-vivo, interoceptive, imaginal, response prevention) with targets; additional skills (relaxation, sleep hygiene, problem-solving, emotion regulation); care coordination with PCP/psychiatry if occurred.] (Name techniques and targets. Omit intervention types not used. Do not include session dialogue or therapist hypotheses.)

Outcomes & Goal Attainment

Standardized Measures:

• [Measure name] — Baseline: [date], [score], [severity band]. Discharge: [date], [score], [severity band]. [Interpretation: clinically significant change / reliable change / minimal / worsened].
• [Additional measures as applicable]
• (If not administered: "Not administered: [reason—patient declined / unplanned discharge / measure not used in program].")

Goal-Level Outcomes:

• Goal 1: [Patient-centered behavioral goal]. Status: [Met / Partially Met / Not Met / Unable to Assess]. Evidence: [measure change, behavioral milestones, functional improvements]. Barriers: [factors limiting attainment]. Ongoing: [what remains].
• Goal 2: [Goal]. Status: [status]. Evidence: [evidence]. Barriers: [barriers]. Ongoing: [next steps].
• (Add or remove goals as appropriate.)

Risk & Safety at Discharge

Suicide/Self-Harm: [Denies / Endorses] current ideation; [presence/absence] of intent and plan; [recent self-harm behaviors: none / describe]. [Relevant history]. [Current protective factors].

Violence/Substance Risk: [Document if clinically relevant; otherwise omit.]

Safety Plan: [Exists / Updated on date / Not in place]. [Location: in chart / provided to patient]. [Lethal means counseling: addressed / not indicated].

Rationale for Discharge: [Brief clinical rationale for appropriateness of outpatient discharge referencing current presentation and supports].

(If unable to assess: "Unable to assess at discharge; last risk assessment on [date] indicated [summary].")

Relapse Prevention Plan

Skills to Continue: [List 3–6 core skills learned and when to use them].

Personal Triggers & Warning Signs: [Patient-specific triggers], [early warning signs: sleep changes, avoidance, cognitive patterns, interpersonal stressors].

Maintenance Plan: [Ongoing practice schedule], [anticipated high-risk periods and planned supports].

Coping Escalation: Mild symptoms: [self-management steps, resume specific exercises]. Moderate: [increase structure, contact supports, consider booster]. Severe: [crisis line, urgent evaluation, ED if safety concerns].

Support System: [Who patient will contact, agreed roles].

Crisis Resources: [Crisis line numbers], [instructions for emergencies including when to go to ED].

Booster Sessions: [Planned / Recommended timing] (Omit if not applicable.)

Follow-Up Recommendations

Level of Care: [No ongoing treatment / PRN return / Scheduled boosters / Continued outpatient therapy / Group CBT / Psychiatry / IOP/PHP / Specialty program].

Referrals: [Recipient, date, purpose; records sent to whom and date]. (Omit if none.)

Appointments: [Scheduled appointments] or [Instructions provided for scheduling].

Return Precautions: [Specific symptom thresholds or changes that should prompt re-contact or urgent evaluation].

If Patient Declined Recommended Care: [Discussion summary, patient's stated reason, risk mitigation steps taken]. (Omit if not applicable.)

Clinician Signature

Clinician: [Name, credentials]

Signature Date: [Date]

(Meta-instructions: Use specific dates and scores rather than vague descriptors. When information is missing, explicitly state reason rather than leaving blank. Do not infer diagnoses, stability, or safety status without supporting documentation. Omit intervention subsections not applicable, but always include Risk & Safety, Relapse Prevention, and Follow-Up Recommendations.)