Every therapeutic relationship ends eventually. Whether your client achieves their goals, relocates, or simply stops responding to outreach, how you document that ending matters. A well-written termination summary protects you legally, supports continuity of care, and provides closure for both therapist and client.
Termination summaries (also called discharge summaries) are among the most overlooked clinical documents. Therapists often rush through them or skip them entirely when cases end unexpectedly. This guide provides everything you need to document therapy endings properly, including a downloadable template and real-world examples.
Why Termination Summaries Matter
Think of your termination summary as the closing chapter of a client's story with you. It captures what happened, what changed, and what comes next. Without it, anyone reviewing the record later has no idea how or why treatment ended.
Termination summaries serve multiple critical functions: legal protection if questions arise later, continuity of care if the client seeks treatment elsewhere, insurance documentation for claims, and professional accountability for your clinical decisions.
Without Proper Termination Documentation
- x No record of treatment outcomes or progress
- x Future providers lack critical clinical history
- x Vulnerable to licensing board complaints
- x Insurance audits may flag incomplete records
- x Malpractice risk increases significantly
With Complete Termination Documentation
- + Clear record of clinical reasoning and outcomes
- + Smooth handoffs to other providers
- + Protected against complaints and lawsuits
- + Insurance compliance maintained
- + Professional standards demonstrated
Types of Termination and How to Document Each
Not all therapy endings look the same. Your documentation approach should match the type of termination. Here are the five main categories you will encounter in practice.
| Termination Type | When It Happens | Documentation Focus |
|---|---|---|
| Planned/Mutual | Goals achieved, both parties agree treatment is complete | Comprehensive summary with full outcome data and relapse prevention plan |
| Client-Initiated | Client decides to end, may or may not give reason | Document stated reason, express concerns if applicable, note any safety considerations |
| Therapist-Initiated | Referral needed, ethical conflict, outside scope | Clear clinical rationale, referral information, client notification documentation |
| Lost to Follow-up | Client stops attending without notice | Document all outreach attempts with dates and methods |
| Administrative | Insurance changes, relocation, therapist retirement | Explain external circumstances, provide referrals, ensure care continuity |
10 Required Elements for Every Termination Summary
Regardless of how therapy ends, certain elements must appear in your documentation. Missing any of these could create problems during audits, records requests, or legal proceedings.
Termination Summary Checklist
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1.
Reason for termination
State clearly why treatment ended (goals met, client request, lost to follow-up, etc.)
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2.
Treatment dates
Include both start date and termination date
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3.
Number of sessions
Total sessions attended, including no-shows and cancellations if relevant
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4.
Diagnosis at intake and termination
Show diagnostic changes over course of treatment
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5.
Summary of presenting problems
Brief description of what brought client to treatment
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6.
Treatment modalities used
CBT, DBT, EMDR, psychodynamic, or other approaches
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7.
Progress toward goals
Met, partially met, or not met for each treatment goal
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8.
Client status at termination
Current symptom levels, functioning, and any remaining concerns
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9.
Recommendations for future care
Maintenance strategies, warning signs, when to return to treatment
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10.
Referrals made
Names and contact information for any providers client was referred to
Complete Termination Summary Example
Here is a real-world example of a well-documented planned termination. Notice how each required element is addressed with specific, measurable information.
TERMINATION SUMMARY
Client: [Redacted]
DOB: [Redacted]
Treatment Start: March 15, 2024
Treatment End: January 10, 2025
Total Sessions: 32 (28 attended, 4 cancelled)
Session Frequency: Weekly x 24, then biweekly x 8
Termination Type: Planned/Mutual
Therapist: [Name, Credentials]
Diagnosis:
At intake: F32.1 Major Depressive Disorder, Moderate
At termination: F32.5 Major Depressive Disorder, In Full Remission
Presenting Problems:
Client presented with depressed mood, anhedonia, sleep disturbance (4-5 hours per night), poor concentration, and passive suicidal ideation without intent or plan. Symptoms began approximately 6 months prior following unexpected job loss. PHQ-9 score at intake was 18 (moderately severe).
Treatment Provided:
Individual psychotherapy using Cognitive Behavioral Therapy (CBT) with emphasis on cognitive restructuring and Behavioral Activation. Treatment included sleep hygiene education, activity scheduling, identification and modification of negative automatic thoughts, and development of coping strategies for stress management.
Progress Toward Goals:
- Goal 1: Reduce PHQ-9 from 18 to below 10 - MET (final score: 4)
- Goal 2: Establish regular sleep schedule of 7+ hours - MET (averaging 7.5 hrs/night)
- Goal 3: Engage in meaningful activities at least 5x weekly - MET
- Goal 4: Secure stable employment - MET (new position obtained 4 months ago)
Client Status at Termination:
Client reports stable mood, consistent sleep, active social engagement, and satisfaction with new employment. Denies current depressive symptoms. No suicidal ideation for past 6+ months. Client demonstrates strong understanding of CBT concepts and can independently identify and challenge negative thinking patterns. Expressed confidence in maintaining gains.
Recommendations:
- Continue using cognitive restructuring techniques when negative thoughts arise
- Maintain physical exercise routine (currently 3x weekly)
- Preserve social connections and support network
- Monitor for early warning signs including sleep changes and social withdrawal
- Return to therapy if depressive symptoms persist for 2+ weeks
- Consider booster session in 3-6 months if desired
Documenting Lost to Follow-up Cases
Let's be honest: clients ghost. They stop showing up, stop returning calls, and disappear without explanation. This is one of the most frustrating aspects of clinical work, but it still requires proper documentation.
When Clients Disappear: Documentation Protocol
The standard practice is to make at least three documented outreach attempts before closing a case as lost to follow-up. Your documentation should include the date, method, and outcome of each attempt.
Example Documentation:
- 01/15/2025: Left voicemail at number on file requesting return call to reschedule missed appointment.
- 01/22/2025: Sent letter via USPS to address on file expressing concern about missed sessions and inviting client to contact office.
- 02/05/2025: Third attempt via phone. No answer, voicemail box full. No response to previous outreach attempts. Case closed as lost to follow-up per office policy.
When You Initiate Termination
Sometimes you need to end the therapeutic relationship. Maybe the client needs specialized care you cannot provide. Maybe there is an ethical conflict. Maybe the client is not engaging in treatment. Whatever the reason, therapist-initiated terminations require extra documentation care.
Appropriate Reasons for Therapist-Initiated Termination
- - Client needs exceed your scope of practice
- - Dual relationship or ethical conflict emerges
- - Client is not engaging in or benefiting from treatment
- - Therapist is relocating or retiring
- - Therapeutic relationship has become counterproductive
Required Documentation Elements
- - Clinical rationale for termination decision
- - How client was notified (session, letter, phone)
- - Client's response to termination
- - Referrals provided with contact information
- - Steps taken to ensure continuity of care
Common Termination Documentation Mistakes
After reviewing thousands of clinical records, these are the errors that come up repeatedly. Avoiding these mistakes protects both you and your clients.
Documentation Errors to Avoid
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1.
No termination summary at all
Every case needs a summary, even if the client ghosted after one session.
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2.
Vague outcome descriptions
"Client improved" tells us nothing. Use specific measures and behavioral descriptions.
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3.
No documentation of outreach attempts
When clients disappear, document every attempt to contact them.
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4.
Missing referral information
If you referred the client elsewhere, document who, when, and why.
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5.
Waiting too long to document
Complete termination summaries within one week of the final session.
Frequently Asked Questions
How soon after termination should I complete the summary?
Best practice is within 7 days of the final session or case closure. Waiting longer increases the risk of forgetting important details and may violate some payer or regulatory requirements.
What if the client only attended one session?
You still need a termination summary. It can be brief: document the presenting concern, what was discussed, why treatment did not continue, and any referrals or recommendations made.
Do I need a termination session?
A formal termination session is ideal for planned endings but not always possible. If the client ends treatment abruptly, document the circumstances. The summary is required regardless of whether a termination session occurred.
Should I include information about the final session?
Yes. The termination summary should reference what was covered in the final session, including any relapse prevention planning, discussion of future needs, and the client's emotional response to ending treatment.
How long should I retain termination summaries?
Follow your state's record retention requirements, which typically range from 7 to 10 years for adults and longer for minors (usually until age 21 plus several years). When in doubt, retain longer.
Key Takeaways
- 1. Every therapy case needs a termination summary, regardless of how treatment ended or how many sessions occurred.
- 2. Include all 10 required elements: reason for termination, dates, session count, diagnoses, presenting problems, treatment modalities, goal progress, client status, recommendations, and referrals.
- 3. For lost to follow-up cases, document at least three outreach attempts before closing the file.
- 4. Complete termination summaries within one week of the final session to ensure accuracy.
- 5. Use measurable outcomes and specific behavioral descriptions rather than vague statements like "client improved."
Proper termination documentation is one of those clinical tasks that feels tedious until you need it. When a client returns to treatment years later, when their new provider requests records, or when you face a licensing board complaint, you will be grateful for complete, professional termination summaries. Take the time to do it right.
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TheraFocus Team
Clinical Documentation Experts
The TheraFocus team is dedicated to empowering therapy practices with cutting-edge technology, expert guidance, and actionable insights on practice management, compliance, and clinical excellence.