Termination Notes

What Are Termination Notes?

A termination note (also called a discharge summary) is a distinct clinical document created when therapy ends. Unlike a regular progress note, a termination note summarises the entire course of treatment and explains why therapy concluded.

When to Write a Termination Note

Write a termination note whenever a case closes, regardless of how it ends:

• Planned termination — treatment goals met or mutual agreement to end
• Client-initiated termination — the client decides to stop, including against clinical advice
• Therapist-initiated termination — scope mismatch, lack of progress, or boundary concerns
• Loss of contact — the client stops attending without explanation

For a detailed framework on managing each scenario, see our therapy termination guide.

Required Elements

Reason for Termination

State explicitly whether termination was therapist-initiated, client-initiated, or mutual. Include the clinical rationale.

Summary of Presenting Problems

What the client came to therapy for, including diagnosis codes.

Treatment Provided

A concise summary of modalities and interventions used, number of sessions attended, and duration of treatment.

Progress Toward Treatment Goals

Goal-by-goal assessment referencing the treatment plan. Use measurable language: “Client’s PHQ-9 score decreased from 18 (moderately severe) at intake to 6 (mild) at termination.”

Current Clinical Status

Functioning level at termination, outstanding risk factors, and any remaining symptoms.

Risk Assessment

Even at termination, document that you screened for safety concerns.

Referrals Provided

Specific names, contact information, and reasons for referral. “Referral provided” without specifics is insufficient.

Relapse Prevention Plan

The strategies, supports, and re-engagement triggers discussed with the client.

Client’s Response to Termination

How the client reacted to ending therapy — this is clinically relevant and legally protective.

Common Mistakes

• Using vague language about “mutual agreement” without specifying who raised termination first
• Omitting referrals or providing only generic referral information
• Skipping the risk assessment because the client is “doing well”
• Writing the termination note as a standard progress note rather than a comprehensive summary