Therapy Discharge Summary Template
Description:
This template is designed to document the therapy discharge process. It provides a structured summary of the treatment provided, the client’s progress, final assessments, and recommendations for future care as the client transitions out of therapy. Use this template to ensure a comprehensive and consistent discharge record.
Date: [Record the date of discharge]
Client Name: [Enter the client’s full legal name]
Therapist Name: [Enter the therapist’s full name]
Therapy Duration: [Record the start and end dates of therapy]
Summary of Treatment:
Original Goals and Objectives:
[List the initial treatment goals established at the start of therapy.]Progress and Outcomes:
[Summarize the client's progress toward these goals, noting any key achievements or milestones.]Interventions Used and Their Effectiveness:
[Detail the therapeutic interventions employed during the treatment and assess their impact.]
Final Assessments:
Standardized Measures:
[Include final scores from any assessments (e.g., PHQ-9, GAD-7) and compare them to initial scores.]Observations and Clinical Impressions:
[Record any final observations regarding the client’s mental health status, coping skills, and overall progress.]
Client Feedback:
Overall Satisfaction with Therapy:
[Document the client’s satisfaction with the therapy process.]Comments and Suggestions:
[Include any feedback provided by the client regarding their therapy experience.]
Discharge Details:
Reason for Discharge:
[Explain the rationale for discharge (e.g., therapy goals met, client request, referral to another service, etc.)]Final Risk Assessment:
[Assess the current risk level and note any protective factors that will support the client post-discharge.]
Recommendations and Follow-Up:
Recommendations for Continued Support:
[List any suggestions for maintaining progress after discharge (e.g., self-help strategies, community resources).]Referrals:
[Include any referrals to additional services or support groups, if applicable.]Follow-Up Plan:
[Outline the plan for any follow-up appointments or check-ins.]
Therapist's Final Observations:
[Record any concluding observations, recommendations for future care, and final thoughts regarding the therapy process.]
Therapist's Signature: _____________________ Date: ______________
Client's Acknowledgment (optional): _____________________ Date: ______________
Therapy Discharge Summary Template (Filled Mock Document)
Date: July 10, 2025
Client Name: Jane Smith
Therapist Name: Dr. Michael Green
Therapy Duration: January 5, 2025 – July 5, 2025
Summary of Treatment:
Original Goals and Objectives:
Reduce anxiety symptoms (GAD-7 score from 14 to below 8).
Enhance coping skills and overall resilience.
Improve quality of life and daily functioning.
Progress and Outcomes:
GAD-7 score improved to 6, meeting the target.
Jane reports significant improvements in managing anxiety and stress.
Overall daily functioning and social engagement have markedly improved.
Interventions Used and Their Effectiveness:
Cognitive Behavioral Therapy (CBT) was central to reducing anxiety.
Mindfulness practices were integrated to support stress reduction.
Skills training bolstered Jane’s coping strategies.
Final Assessments:
Standardized Measures:
GAD-7: Initial score 14, final score 6.
PHQ-9: Initial score 12, final score 5.
Observations and Clinical Impressions:
Jane presents as stable, equipped with effective self-management tools, and demonstrates enhanced resilience.
Final assessments support significant clinical improvement.
Client Feedback:
Overall Satisfaction with Therapy:
Jane expressed high satisfaction with her progress and the therapeutic process.
Comments and Suggestions:
She appreciated the combination of CBT and mindfulness.
Jane suggested occasional follow-up sessions to reinforce her newly acquired skills.
Discharge Details:
Reason for Discharge:
Therapy goals have been met, and Jane is prepared to transition out of active therapy.
Final Risk Assessment:
The current risk level is low, with strong protective factors including family support and improved self-management techniques.
Recommendations and Follow-Up:
Recommendations for Continued Support:
Continue practicing mindfulness and CBT techniques independently.
Maintain a structured daily routine to self-monitor anxiety levels.
Referrals:
Participation in a local support group is recommended for ongoing mental wellness.
Follow-Up Plan:
A follow-up session is scheduled for three months post-discharge to assess the maintenance of progress.
Therapist's Final Observations:
Jane has shown remarkable improvement throughout therapy. The skills acquired during sessions have provided her with effective tools to manage stress and anxiety. Continued self-practice and occasional check-ins are recommended to ensure sustained progress.