With the client you selected in mind, address in a client termination summary (without violating HIPAA regulations) the following:
- Identifying information of client (e.g., hypothetical name and age)
- The date the client initially contacted the therapist, date therapy began, duration of therapy and date therapy will end
- Total number of sessions, including the number of missed sessions
- Whether termination was planned or unplanned
- Presenting problem
- Major psychosocial issues
- Types of services rendered (e.g., individual, couple/family therapy, group therapy)
- Overview of the treatment process
- Goal status (goals met, partially met, unmet)
- Treatment limitations (if any)
- Remaining difficulties and/or concerns
- Recommendations
- Follow-up plan (if indicated)
- Instructions for future contact
- Signatures
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