Therapy Discharge Summary Example: 3 Samples and a Template

Search for a discharge summary example and most of what comes back is written for hospitals: admission dates, the hospital course, a medication list. A discharge summary in outpatient therapy does a different job. It closes one episode of care, records what treatment did for each goal, and tells the next clinician, or you if the client comes back in two years, where things stood at the end. This guide is for therapists, counselors and social workers in outpatient and private practice, not hospital discharge.

Below you'll find a template you can copy, one field per line, and three complete examples: a planned completion, a client who stopped attending, and a referral to a higher level of care. After those come what the ACA, NASW, APA and AAMFT codes say about ending therapy, how to document a client who stops showing up, and two short discharge letters you can send to the client.

Every client in this article is invented. Any resemblance to a real person is a coincidence.

What a discharge summary is in outpatient therapy

A discharge summary, also called a termination summary, closing summary or discharge note, is the last document in a client's record for an episode of care. A progress note covers one session. The discharge summary covers the whole course: why the client came, what you did, what changed on each goal, the risk at the end, and what happens next.

It differs from a hospital discharge summary in what it centers on. There is usually no hospital course and no medication list you manage. The core is the treatment plan: each goal, where it started, where it ended, and how you know.

Four kinds of reader rely on it:

A discharge summary is part of the clinical record, not a psychotherapy note. HIPAA's definition of psychotherapy notes leaves out "any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date" (45 CFR 164.501). That list is close to a description of a discharge summary.

It is also not the same as the last session's note. If you hold a final session, write its progress note as usual, in SOAP, DAP or whatever format you use, then write the summary as a separate document. For a client who stopped coming, there is no final session note, and the summary also records your attempts to reach them.

When to write a discharge summary

Write one every time an episode of care ends, however it ends:

How soon. Private practice has no single federal deadline. Agencies, county contracts and some payers set one, often 30 days from the last contact. Set your own rule in your policies and follow it. A practical one: within a week of the last session for a planned ending, and on the closing date in your letter for a client who stopped coming.

What to include in a therapy discharge summary

Most agency forms and the ranking templates agree on the core. Here is the full list for outpatient therapy, in the order the template below uses:

Leave out:

Length. One to two pages, about 300 to 700 words for most outpatient clients. Long treatment or a complex referral can run longer.

A discharge summary template you can copy

Paste this into your notes, delete what doesn't apply, and repeat the goal block for each goal. It works as a termination summary template for counseling, social work or psychology practice.

Discharge summary example 1: planned completion

Invented client: a 29-year-old graphic designer we'll call Priya, seen by video for panic attacks.

Reason for referral: Self-referred after two emergency room visits for chest pain; her physician found no cardiac cause. At intake she said, "I'm scared to go anywhere I can't leave quickly." She had stopped driving on highways and was working from home full time.

Diagnosis: F41.0 Panic disorder at intake and at discharge. No panic attacks in the last eight weeks; see status below. No new diagnosis during treatment.

Services provided: CBT for panic: psychoeducation about the panic cycle, interoceptive exposure, work on catastrophic readings of body sensations, and graded exposure to highway driving. Her primary care physician was updated at session 8 and at discharge (release signed 3/11). No psychiatric medication.

Progress on treatment plan goals:

Status at discharge: Still notices a racing heart after coffee or a hard climb; she now names it ("that's just my heart working") and carries on. Sleeping about seven hours. At the last session: bright, relaxed, talking about a long drive she has planned for a vacation.

Risk at discharge: Asked about thoughts of suicide and of harming others at intake, at session 8 and on 7/22; she denied both each time. No past attempts. No risk factors emerged during treatment. A safety plan was not indicated. Risk assessed as low at intake and at discharge.

Reason for discharge: Planned completion. All three goals met. Ending first discussed at session 12; sessions spaced to every other week for the last four to test the gains.

Recommendations: Keep one "booster" exposure a month, such as driving a new route. Repeat the interoceptive exercises if avoidance starts to creep back. Routine follow-up with her physician. No referral needed.

Aftercare plan: Warning signs, in her words: "checking my pulse, picking routes without highways, working from home just this week." Return to therapy if she has two or more attacks in a month or avoids driving for more than two weeks. Written relapse prevention plan made at session 15; she has a copy. Crisis resources given: 988.

Who was informed: Client, at the final session on 7/22. Primary care physician: short discharge letter sent 7/24 (release signed 3/11).

Client's view: "I didn't think I'd ever drive to work again."

Prognosis: Good. She uses the skills without prompting, and her gains held across four sessions at lower frequency.

Why this summary works:

Discharge summary example 2: the client stopped attending

Invented client: a 46-year-old warehouse supervisor we'll call Graham, seen in the office for depression after his divorce.

Reason for referral: Referred by his physician. At intake: "I go to work, I come home, I sit there." Low mood, poor sleep and pulling away from his children since the divorce six months earlier.

Diagnosis: F32.1 Major depressive disorder, single episode, moderate. Unchanged at discharge.

Services provided: Behavioral activation (activity scheduling, then graded activities with his children) and work on self-critical thoughts about the divorce. No other providers involved. He declined a release for his physician at intake.

Progress on treatment plan goals (as of the last session, 6/17):

Status at discharge: Unknown since 6/17. At that session he reported better mood on the weekends with his children and still woke early most days. He said his shift was moving to evenings in July and wasn't sure how that would fit with his appointments.

Risk at last contact (6/17): PHQ-9 item 9 scored 0. Asked directly about thoughts of suicide; he denied any. Denied thoughts of harming others. No past attempts. No firearms in the home (asked at intake). Protective factors: his children, his job, regular contact with his sister. Because risk was not elevated at the last contact, the practice's standard outreach steps were followed.

Outreach:

Each contact has its own dated contact note in the record.

Reason for discharge: Client stopped attending. No response to four contacts over three weeks. Closed under the attendance policy in the informed consent he signed on 5/6: outreach after a missed session, then a closing letter with a two-week deadline.

Recommendations: Resume therapy; evening appointments offered. Referrals in the letter: two clinicians with evening hours and a community mental health clinic. Follow up with his physician about mood.

Aftercare plan: In the letter: how to book again, and crisis resources (988 or the nearest emergency room).

Who was informed: Client by letter on 7/2. No other providers: no release on file.

Client's view: Not available: no contact since 6/17.

Prognosis: Fair. Partial response to treatment before it stopped.

Why this summary works:

Discharge summary example 3: referral to a higher level of care

Invented client: a 45-year-old restaurant manager we'll call Luis, seen in the office for anxiety and insomnia. Drinking became the main concern during treatment.

Reason for referral: Self-referred. At intake: "My mind won't shut off at night." Worry about work, trouble falling asleep, and a few drinks most nights "to switch off."

Diagnosis: At intake, F41.1 Generalized anxiety disorder. At discharge, F41.1 Generalized anxiety disorder and F10.20 Alcohol use disorder, moderate (added at session 9, when the history from sessions 6 to 9 met criteria).

Services provided: CBT for worry and insomnia (sessions 1 to 5); motivational interviewing and a drinking log (sessions 6 to 11). His primary care physician was involved from session 9 (release signed 9/2).

Progress on treatment plan goals:

Status at discharge: Shaky most mornings until his first drink, which he described as "steadying my hands." Two attempts to cut down on his own since session 7, each lasting under two days. Missed two shifts in September. At the last session: tired, anxious, open about the drinking, and relieved that a plan was in place.

Risk at discharge: Asked about thoughts of suicide and of harming others at each session from session 6; he denied both each time. No past attempts. No firearms in the home. Denied driving after drinking. The main risk is medical: possible withdrawal if he stops suddenly. He was advised on 9/16 not to stop drinking abruptly on his own and to see a physician first, and he saw his physician on 9/18.

Reason for discharge: Referral to a higher level of care. Weekly outpatient therapy was no longer enough: drinking rose despite treatment, he showed signs consistent with physical dependence, and two attempts to cut down alone failed. Discussed at sessions 10 and 11; he agreed.

Recommendations and referrals: Medical assessment for withdrawal management through his physician (seen 9/18). Admission to a hospital-based intensive outpatient program for alcohol use (intake 9/23, admitted 9/25). A mutual-help group of his choice. Return to outpatient therapy for anxiety after the program if he wants it.

Bridge care: Weekly sessions continued until the program took over (9/16 and 9/22), so there was no gap in care.

Aftercare plan: Follow the program's plan and his physician's instructions. Crisis resources given: 988, or the nearest emergency room for severe withdrawal symptoms such as confusion, seizures or hallucinations.

Who was informed:

Client's view: "I kept telling myself I could handle it. I can't, not alone."

Prognosis: Guarded for alcohol use without the higher level of care; fair with it, given his engagement and family support.

Why this summary works:

How the three summaries differ

Termination ethics: what the codes require

Each major code says much the same thing in different words: end therapy when it is no longer helping, prepare the client, offer other options, and don't leave someone who still needs care without a way forward.

ACA (counselors). "Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling." Counselors may also end counseling when they are at risk of harm from the client or someone close to them, or when fees go unpaid as agreed, and they "provide pretermination counseling and recommend other service providers when necessary" (A.11.c). When transferring, counselors complete "appropriate clinical and administrative processes" and keep communication open with the client and the new provider (A.11.d). And: "Counselors do not abandon or neglect clients in counseling," including arranging continued care "following termination" (A.12). The ACA defines abandonment as "the inappropriate ending or arbitrary termination of a counseling relationship that puts the client at risk" (ACA Code of Ethics).

NASW (social workers). Social workers should end services "when such services and relationships are no longer required or no longer serve the clients' needs or interests" (1.17(a)), "take reasonable steps to avoid abandoning clients who are still in need of services," and withdraw services "precipitously only under unusual circumstances" (1.17(b)). Ending over an overdue balance is allowed only if the fee arrangement was clear, the client "does not pose an imminent danger to self or others," and the consequences have been discussed (1.17(c)). When you expect an ending, "notify clients promptly" (1.17(e)). When referring, disclose "with clients' consent, all pertinent information to the new service providers" (1.16(b)) (NASW Code of Ethics, Section 1).

APA (psychologists). Standard 10.10 mirrors the ACA: terminate "when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service"; you may terminate when threatened; and "Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate" (APA Ethics Code). The "actions of clients" clause covers the client who simply disappears: you can't counsel someone who won't answer, but you can still send referrals.

AAMFT (marriage and family therapists). The revised code effective January 1, 2026: "Marriage and family therapists do not terminate treatment with clients without making reasonable efforts to provide appropriate arrangements for the continuation of care" (1.10) (AAMFT Code of Ethics).

Your state board's rules sit on top of these and can be stricter.

What abandonment looks like, and what it doesn't

Usually abandonment:

Usually not abandonment:

What to write down

The discharge summary is where your ethics become visible. Record the date you first raised the ending, the referrals you offered and how the client responded, the crisis resources you gave, and, for a transfer or step up, each contact with the new provider and the release that allowed it.

How to document a client who stops showing up

In private practice, more therapy episodes end with silence than with a final session. A clear routine protects the client and makes your record easy to follow.

What to write, and what not to:

Don't keep a silent client open for months. An open chart says you are still the treating clinician. A summary and a letter make the status clear to the client and to anyone who reads the record later.

The discharge letter to the client

A short letter closes the loop in writing. Keep it brief and warm, and leave the diagnosis and session content out: letters are often read by other people in a household. Send it by the contact method the client agreed to and keep a copy in the record. Some therapists use certified mail so they have proof of sending; weigh that against privacy, since someone else may sign for it.

After a planned ending:

For a client who stopped attending:

For a transfer or a referral, add one line naming the new clinician or program and saying you have sent them a summary with the client's permission.

How this works in TranqBay

TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions, session notes and a form library in one place. Here is where a discharge summary fits.

Frequently asked questions about therapy discharge summaries

Before your next ending

Copy the template into your notes now, while no ending is pending, and add a no-contact line to your consent form if it doesn't have one. When the next episode ends, you'll fill in fields instead of starting from a blank page, and the three examples show what each kind of ending needs.

If you want booking, video sessions and session notes in one place, look at a practice website template and the booking page a former client would use to come back. If you're deciding whether to join, this page explains how joining TranqBay works.

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