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Therapy discharge summary template
Use this when closing a therapy episode—document why treatment ends, what improved, what remains, and clear aftercare so the next clinician (or the client) has a usable handoff.
Template content
Copy or download, then paste into Wavo under My Templates.
Therapy Discharge Summary Episode Information - Date of first and last sessions, total sessions attended/no-shows, modality, and diagnosis/focus of care. Reason for Discharge - Planned completion, mutual agreement, client dropout, relocation, higher level of care, or administrative reason. - Client’s stated reasons if available. Course of Treatment - Brief summary of presenting problems, interventions used, and overall trajectory. - Notable milestones, setbacks, and engagement pattern. Goals & Outcomes - Status of each treatment goal (met, partially met, not met) with brief evidence. - Symptom/functioning change (include scores if tracked). Gains & Skills - Coping skills, insight, and behavioral changes the client can continue independently. Risk at Discharge - Current SI/HI/self-harm status, risk level, and rationale. - Safety plan status if applicable. Aftercare Recommendations - Continued therapy, psychiatry/med management, peer support, crisis resources, and self-care plan. - Recommended timeframe for re-engaging care if symptoms return. Final Disposition - Discharge date, records/transfer requests, and any pending coordination completed.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Captures episode narrative and goal outcomes without rewriting every progress note.
- Makes discharge reason and risk-at-discharge explicit for continuity and audits.
- Includes aftercare and relapse-prevention recommendations clients can act on.
- Works for planned completion, mutual termination, and administrative closures.
- 1Planned psychotherapy episode completion
- 2Transfer or relocation terminations
- 3Clinic closures and administrative discharges
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Episode Information Weekly CBT for social anxiety, 14 sessions over 4 months. First visit 2026-02-03; final visit today. Diagnoses: social anxiety disorder. Reason for Discharge Planned completion; goals substantially met; client starting new role out of state. Goals & Outcomes Goal 1 (attend meetings without avoidance): met—attending consistently × 6 weeks. Goal 2 (reduce GAD-7): met—15 → 6. Goal 3 (one social event/week): partially met—3 of 4 weeks. Risk at Discharge Denies SI/HI. Risk low. Crisis resources reviewed. Aftercare Recommendations Booster session PRN via telehealth within 3 months if avoidance returns. Continue exposure maintenance list. Psychiatry not indicated now. Provided local therapist referral options in new city. Final Disposition Discharged today. Summary offered to client; no transfer request at this time.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.