2 pages

[INSERT PRACTICE NAME OR LOGO]

Termination Summary

Client: Date:

Signature(s) of therapist(s): ___________________________________

A. Main reason for termination

❑ The planned treatment was completed. ❑ The client refused to receive or participate in services.

❑ The client was unable to afford continued treatment or did not pay bills on time. ❑ Client moved.

❑ There was little or no progress in treatment. ❑ This is a planned pause in treatment.

❑ The client needs services not available here, and so was referred to:

❑ Other: _____________________________________________________________________________________

B. Source of termination decision

The decision to terminate was: ❑ Client-initiated ❑ MCO-affected ❑ Therapist-initiated ❑ A mutual decision

❑ Other: ___________________________________________________________

C. Treatment sessions

Date of first contact: ______________ Date of last session: ____________

Number of sessions: Scheduled: _______ Attended: ______ Cancelled: ______ Did not show: ________________

D. Kinds of services rendered

❑ Individual psychotherapy, for ______ sessions ❑ Couple/family therapy, for ______ sessions

❑ Group therapy, for _____ sessions ❑ Other: ______________________________________________________

E. Treatment goals and outcomes

Presenting Problem(s):

Goal:

Outcome:

ADDRESS:

PHONE:

FAX:

EMAIL:

WEBSITE: