Discharge Summary Template: When and How to Write One

Closing the Loop With Good Documentation

Ending therapy — whether because goals were met, the client chose to stop, or you're referring them elsewhere — deserves the same documentation care as the intake. A discharge summary closes the clinical record, summarizes outcomes, and provides continuity if the client returns to treatment later.

When to Write a Discharge Summary

Write a discharge summary when:

**Treatment goals have been met** and the client is ready to terminate

**The client discontinues** against clinical recommendation (document this clearly)

**You're referring** the client to another provider or level of care

**You're closing your practice** or the client is moving away

**Insurance or agency policy** requires formal discharge documentation

Don't skip discharge documentation because the ending feels mutual and positive — the summary protects both you and the client.

What to Include

A complete discharge summary covers:

**Dates of service** — first and last session dates

**Reason for discharge** — goals met, client request, referral, etc.

**Summary of treatment** — modalities used, number of sessions, key interventions

**Progress toward goals** — status of each treatment plan goal

**Current clinical status** — where the client stands at discharge

**Final risk assessment**

**Recommendations** — follow-up care, community resources, return criteria

**Client response** to discharge plan

Copy & Paste Discharge Summary Template

**Dates of Service:** [Start date] to [End date]. Total sessions: [number].

**Reason for Discharge:** Client discharged from treatment due to [goals met / client request / referral to higher level of care / relocation / other — specify].

**Treatment Summary:** Client was seen for [frequency] individual therapy sessions over [duration]. Treatment utilized [modality — CBT, EMDR, etc.] targeting [primary diagnosis/concerns]. Key interventions included [list 2–3 major interventions].

Progress Toward Goals:

Goal 1: [goal text] — Status: [Met / Partially met / Not met — with brief explanation]

Goal 2: [goal text] — Status: [Met / Partially met / Not met]

Goal 3: [goal text] — Status: [Met / Partially met / Not met]

**Current Clinical Status:** At discharge, client presents with [symptom summary]. [Include final scale scores if applicable — e.g., "Final PHQ-9: 4, down from intake score of 18."] Client demonstrates [skills gained, coping strategies, insight level].

**Risk Assessment at Discharge:** [No acute risk factors identified / describe current risk status and safety plan if applicable].

**Recommendations:** Client advised to [return to therapy if symptoms recur / follow up with psychiatrist / continue medication management / utilize community supports such as support groups]. Client provided with [list of resources]. Return to treatment recommended if [specific criteria — e.g., PHQ-9 rises above 10, suicidal ideation returns, functional impairment recurs].

**Client Response:** Client [expressed satisfaction with progress / acknowledged mixed feelings about ending / requested early termination despite clinical recommendation]. Client verbalized understanding of discharge plan and recommendations.

Discharge Scenarios That Need Extra Care

**Client terminates against clinical advice:** Document your recommendation to continue, the client's stated reason for leaving, current risk status, and that you provided resources and return criteria. Note whether you offered a closing session.

**Referral to higher level of care:** Document why the current level of care is insufficient, what you're referring to (IOP, PHP, psychiatry, etc.), and steps taken to facilitate the referral.

**Unplanned discharge (client no-shows):** After following your agency's no-show/termination policy (typically 30 days of no contact after outreach attempts), document attempts to reach the client, last known clinical status, and that the chart is closed.

The Final Session Matters

Even with a written discharge summary, the last session should include:

Reviewing progress together

Acknowledging the therapeutic relationship

Discussing relapse prevention and return criteria

Providing written resources and recommendations

Processing feelings about ending (for both of you)

Your discharge summary reflects this conversation — it shouldn't be the first time the client hears that therapy is ending.

Discharge summaries pull together months of work into one document — and that's exactly where TherapistNote can help. Generate a structured discharge summary from your treatment history and session notes, then review and personalize it before adding to the client's chart.