TemplatesLast updated: October 29, 2026

Therapy Discharge Summary Template

A discharge summary closes an episode of therapy: why it ended, what changed, where the client stands and what comes next. Below is a template for outpatient therapy you can paste into your EHR, a guide to each section and two filled examples, one planned and one unplanned. The examples are fictional composites. Hospital and inpatient discharge summaries follow a different, medical format.
Go to the template
By Jesse, Registered Psychotherapist.6 min read

On this page

Template

Plain text to copy

Pastes into an EHR text box

Examples

Fictional composites

No real clients

Reading time

6 min read

Adapt it to your setting

The template

Template
Therapy Discharge Summary
Client: [identifier]   Clinician: [name, credentials]
First session: [date]   Last session: [date]   Discharge date: [date]
Sessions attended: [number attended of number scheduled]
Type of discharge: [planned / unplanned]
Diagnosis or clinical impression at intake: [if within your license's scope]
Diagnosis or clinical impression at discharge: [if within your license's scope]

1. Presenting concerns at intake: [ ]
2. Reason for discharge: [goals met / client's choice / referral to another
   service or level of care / relocation / stopped attending / other]
3. Treatment provided: [modality, frequency, main interventions]
4. Progress toward treatment-plan goals:
   Goal 1: [met / partly met / not met; evidence]
   Goal 2: [ ]
5. Measures at intake and at discharge: [ ]
6. Risk at discharge: [what you asked about thoughts of suicide, self-harm
   or harm to others; risk judgment and reasoning; safety-plan status]
7. Condition and functioning at discharge: [ ]
8. Recommendations: [skills to keep using, warning signs, when to return]
9. Referrals and resources given: [services; crisis resources such as the
   988 Suicide and Crisis Lifeline]
10. Ending process: [how ending was discussed; final session, or contact
    attempts with dates and method]
11. Coordination: [records sent or providers informed, with written consent]

Signature, credentials, date: [ ]
Supervisor co-signature (if required): [ ]

What goes in each section

Reason for discharge. State it plainly. "Goals met; ending agreed in session 12" or "Stopped attending after session 6; no response to three contact attempts" tells the next reader what happened. "Client terminated" does not.

Progress toward goals. Go goal by goal from the treatment plan: met, partly met or not met, with the evidence. Compare the same measures at intake and at discharge.

Risk at discharge. Record the client's risk status at the end, even when there is no concern. For an unplanned discharge, record risk as of the last contact and say so. If risk is present, record your judgment and its reasoning, the safety plan and the referral that continues care.

Recommendations and referrals. What the client can keep doing, the warning signs that would suggest a return to therapy, how to come back and any referrals. Include crisis resources such as the 988 Suicide and Crisis Lifeline.

Ending process. How the ending was handled: discussed ahead of time and reviewed in a final session, or, if the client stopped attending, the dates and methods of each contact attempt and any closing letter.

Ethical termination: planned and unplanned discharge

Professional ethics codes, including the ACA Code of Ethics (its standards on termination and referral), the APA Ethics Code (standard 10.10) and the NASW Code of Ethics (standard 1.17), address ending therapy. In short: end services when the client no longer needs them, is not likely to benefit or is being harmed by continuing; discuss the ending ahead of time where you can; offer referrals when the client still needs care; and do not abandon a client. Your licensing board may add its own rules, so check them.

Planned discharge. The ending is agreed with the client and discussed over the last few sessions where you can. The final session reviews progress, the relapse-prevention plan and how to return.

Unplanned discharge. The client stops attending, leaves without notice or must move to another service quickly. Record each contact attempt and what you sent, such as a closing letter with referrals and crisis resources. Follow your practice policy on when to close the file, and apply it the same way each time. If there were recent risk concerns, follow your setting's protocol for outreach before closing.

Two filled examples

All examples on this page are fictional composites. They do not describe real clients.

1. Planned discharge. Adult in their 30s, panic attacks and avoidance of highway driving, 14 sessions.

Example
Type of discharge: planned
Sessions attended: 14 of 15 scheduled
Presenting concerns at intake: panic attacks about 3 times a week for 6
months; stopped driving on the highway.
Reason for discharge: treatment goals met; ending agreed in session 12.
Treatment provided: weekly individual CBT for panic: psychoeducation,
cognitive restructuring of catastrophic interpretations, interoceptive and
situational exposure.
Progress toward treatment-plan goals:
  Goal 1 (panic attacks 1 or fewer a week): met. No panic attacks in the
  last 6 weeks, by panic log.
  Goal 2 (drive to work on the highway 5 days a week): met. Driving the
  highway on all workdays for 5 weeks.
Measures: Panic Disorder Severity Scale (PDSS, scored 0 to 28): 17 at
intake, 5 at discharge.
Risk at discharge: Denies thoughts of suicide, self-harm or harm to
others; none reported during treatment. Judged low risk.
Condition at discharge: working full time, driving independently, sleeping
7 hours a night.
Recommendations: Keep doing the activities once avoided. Warning signs to
watch: avoiding driving again, checking pulse, skipping outings. Return to
therapy if panic attacks occur weekly for a month. Booster session
offered at 3 months.
Referrals and resources: none needed. Relapse-prevention plan, including
the 988 Suicide and Crisis Lifeline, given to client.
Ending process: ending discussed from session 10; final session reviewed
progress and the relapse-prevention plan.
Coordination: summary sent to primary care provider with written consent.

2. Unplanned discharge. Adult in their 40s, depression, stopped attending after session 6.

Example
Type of discharge: unplanned
Sessions attended: 6 of 9 scheduled
Presenting concerns at intake: low mood for 5 months, missing workdays,
withdrawn from friends.
Reason for discharge: stopped attending after session 6; no response to
three contact attempts over 30 days.
Treatment provided: weekly individual CBT: behavioral activation and
cognitive restructuring.
Progress toward treatment-plan goals:
  Goal 1 (attend all scheduled workdays for 4 weeks): partly met. Missed 1
  workday in the 2 weeks before session 6, down from about 3 a week at
  intake.
  Goal 2 (contact a friend weekly): not met. Contact in 2 of 6 weeks.
Measures: Patient Health Questionnaire-9 (PHQ-9, scored 0 to 27): 19
(item 9: 0) at intake, moderately severe range; 14 (item 9: 0) at session
6, moderate range.
Risk at discharge: Based on the last session: denied thoughts of suicide,
self-harm or harm to others; PHQ-9 item 9: 0; no risk concerns at any
session. Judged low risk at the last contact.
Condition at discharge: improving but still in the moderate range at the
last measure.
Recommendations: continued treatment for depression is recommended.
Referrals and resources: closing letter listed two community mental
health services, the practice's contact details for returning and the
988 Suicide and Crisis Lifeline.
Ending process: phone call and patient-portal message the day after the
missed session; second call one week later; closing letter at 30 days,
per practice policy.
Coordination: none; no release on file.

Common mistakes

  1. No reason for discharge. "Client terminated" leaves the next reader guessing. State why therapy ended.
  2. No goal-by-goal outcome. Record each goal as met, partly met or not met, with evidence.
  3. No risk status at discharge. Record it even when there is no concern.
  4. Closing without referrals when needs remain. If the client still needs care, record the referrals you gave.
  5. No record of contact attempts. For an unplanned discharge, record each attempt with its date and method.

FAQ

What is a discharge summary in therapy?
The closing record of an episode of outpatient therapy. It records why treatment ended, the progress made against each goal, the client's risk status and condition at the end, and the recommendations and referrals that follow.

What should a mental health discharge summary include?
Dates of treatment, sessions attended, type of discharge, the reason for discharge, treatment provided, progress on each goal with measures, risk at discharge, recommendations, referrals and crisis resources, and how the ending was handled. Your agency or payer may require more.

What is the difference between planned and unplanned discharge?
A planned discharge is agreed with the client and ends with a final session. An unplanned discharge happens when the client stops attending or leaves without notice; the summary then records your contact attempts and what you sent.

How long should I wait before discharging a client who stopped attending?
Set a time frame in your practice policy, explain it in your informed consent, and apply it the same way each time. Your agency or payer may set one for you. Record each contact attempt before closing the file.

This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.