Headings
Dates of treatment · Reason for referral · Diagnoses · Treatment provided · Progress toward goals · Reason for discharge · Condition at discharge · Recommendations · Referrals
When to use it
Write it when an episode of care ends, whether goals are met, the client moves on, or care transfers elsewhere. It sums up the whole course in one page: dates, diagnoses, what was done, progress and next steps. It is often the one document a future provider requests, so it stands on its own without the session notes.
Example
Fictional example
Dates of treatment
February 6 to August 28. Sixteen individual sessions.
Reason for referral
P.J., 31. Referred by her OB-GYN for low mood and intrusive worries four months after the birth of her first child.
Diagnoses
Major depressive disorder, single episode, moderate, with peripartum onset.
Treatment provided
Interpersonal therapy focused on role transition. Coordinated with her OB-GYN, who managed sertraline.
Progress toward goals
All three goals met. EPDS fell from 19 to 6. Returned to part-time work in July.
Reason for discharge
Goals met. Mutual decision with client.
Recommendations
Keep her postpartum support group. Return to care if symptoms recur, or early in any future pregnancy.