Although termination is an inevitable part of the therapeutic process, it is often difficult for clients. However, by discussing termination throughout therapy, you can better prepare your clients for life without you. Once a client has achieved his or her therapeutic goals, termination sessions should be held and documented in a client termination summary. For this Assignment, you have the opportunity to practice writing a termination summary for a client with whom you have worked during your practicum experience.
Client selected: 63 year-old African American Female. Client was oriented x3 and engaged in the assessment. Client appeared dressed casually and her grooming and hygiene was fair.
Diagnosis: F31.4( Bipolar disorder, current episode depressed, severe, without psychotic features) and F51.01 ( Primary Insomnia)
Assignment
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)
- Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end
- Total number of sessions, including 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 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