Identifying information of client

With the client you selected in mind, address the following in a client termination summary (without violating HIPAA regulations):

Identifying information of client (i.e., hypothetical name, age, etc.)

Date initially contacted therapist, date therapy began, duration of therapy, and date therapy will end

Total number of sessions, including number of missed sessions

Termination planned or unplanned

Presenting problem

Major psychosocial issues

Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.)

Overview of 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