2026 Discharge summary examples for therapists

[Patient name] presented at intake on [Date] with Generalized Anxiety Disorder (F41.1), moderate severity. Baseline GAD-7: 16. Primary symptoms: daily excessive worry, sleep disturbance, work avoidance, three panic-like episodes in the month prior to intake.

14 weekly individual CBT sessions over 16 weeks (two cancellations rescheduled). Weekly 50-minute sessions throughout. No hospitalizations, no escalations of care during treatment.

Cognitive restructuring via 3-column thought record (sessions 2-14). Behavioral experiments addressing avoidance behaviors (sessions 5-12). Scheduled worry time protocol (sessions 4-10). Sleep hygiene education and stimulus control (sessions 3-4). Progressive muscle relaxation introduced session 6, practiced throughout. No medication coordination — symptoms responsive to therapy alone.

GAD-7 trajectory: baseline 16 → session 4: 13 → session 8: 9 → session 12: 6 → discharge: 5 (within non-clinical range). Sleep onset latency reduced from 90+ minutes to under 20 minutes (self-report log). Zero panic-like episodes since session 9. Patient reported no work avoidance for the final 6 weeks of treatment.

Symptom severity: minimal. GAD-7: 5. PHQ-9: 3. Functioning: full, including work performance and relational stability. Risk: low; denies SI/HI.

Planned termination by mutual agreement. Goals of initial treatment plan substantially met. Patient demonstrated independent skill use over the final 4 sessions.

Re-engagement criteria: GAD-7 rising above 10 for two consecutive weeks, return of sleep disturbance, or re-emergence of work avoidance. Patient encouraged to maintain weekly thought record for 2 months post-discharge. Booster session available; patient may schedule directly via portal. Final session [Date].

[Patient name] presented on [Date] with Borderline Personality Disorder (F60.3) and Persistent Depressive Disorder (F34.1). Two NSSI episodes in the 12 months prior to intake. One prior psychiatric ER visit.

Standard outpatient DBT for 11 months: weekly individual + weekly skills group + 24/7 coach calls available. Patient attended 42 of 44 scheduled individual sessions and 38 of 44 group sessions.

Complete DBT skills curriculum: mindfulness (3 weeks), distress tolerance (10 weeks), emotion regulation (10 weeks), interpersonal effectiveness (8 weeks), back through cycle. Chain analyses on target behaviors. Phone coaching used 12 times across the year. Diary card maintained weekly throughout.

Zero NSSI episodes in past 9 months (target met). Zero psychiatric ER visits during treatment. PHQ-9: baseline 12 → discharge 6. Patient reports skillful management of two major emotional crises in past 90 days. Sertraline 100mg maintained throughout, prescribed by [Provider].

Symptom severity: mild. Risk: low. No active SI/HI; chronic feelings of emptiness substantially reduced. Functioning: stable employment, improved relationship with sister, dating again.

Transfer of care — patient relocating to [Location]. Treatment goals partially met (full DBT curriculum completed once); patient and clinician agreed continuing DBT in the new region is appropriate.

Referred to a CSWMSW-trained DBT clinician at [Location] (warm handoff completed; first appointment scheduled). Sertraline prescription continued by [Provider] with refill bridge until new prescriber is established. Patient retains 24/7 crisis line access until first appointment with new provider. Final session [Date].

[Patient name] presented [Date] with acute PTSD (F43.11) following a motor vehicle accident 5 months prior. Baseline PCL-5: 48. Primary symptoms: intrusive images, nightmares 4x/week, hypervigilance, avoidance of the accident location.

11 weekly EMDR sessions over 12 weeks. Phases 1-2 (history, preparation, resourcing): sessions 1-3. Phase 3 (assessment): session 4. Phases 4-7 (reprocessing through closure): sessions 5-10. Phase 8 (re-evaluation): session 11.

Standard 8-phase EMDR protocol on a single target memory (the accident itself). Tactile bilateral stimulation. Resourcing tools: safe place, container, calm-place body cue. Cognitive interweaves used on the responsibility theme (session 7) and safety theme (sessions 6 and 8). In-vivo driving exposure with therapist on session 10.

Target memory: SUDS at intake 9 → SUDS at discharge 0. Positive cognition 'I am safe now': VOC at intake 2 → VOC at discharge 7. PCL-5: baseline 48 → discharge 9 (well below provisional threshold). Patient drove past the accident location independently for the first time on day 78 of treatment.

Symptom severity: minimal. Functioning: full restoration. Sleep normal (8 hrs avg, no nightmares in past 4 weeks). Risk: low.

Goal completion. Single-incident PTSD reprocessed to adaptive resolution. Patient and clinician agree no further reprocessing is indicated.

Re-engagement criteria: return of nightmares, new intrusive imagery, or re-emergence of avoidance. Patient educated on EMDR availability for future events should they occur. Final session [Date].

[Patient name] presented [Date] with chronic, complex PTSD (F43.12) and Persistent Depressive Disorder (F34.1). Chronic developmental relational trauma. Reported feeling 'split into pieces.' Long history of prior psychotherapy without sustained relief.

28 months of weekly individual IFS therapy. 102 sessions over the course of treatment. Two breaks: one 3-week vacation in year 1; one 2-week period of patient illness in year 2.

IFS protocol throughout. Parts mapping in year 1 identified four core protectors (manager: inner critic; manager: caretaker; firefighter: shutdown; firefighter: numbing). Three exile unburdenings completed across the course of treatment, in close consultation with the patient's protector consensus. Self-energy practice between sessions.

Patient reports stable Self-leadership ≥8/10 across all parts. Inner-critic manager intensity reduced from baseline 9/10 to self-rated 2/10. PHQ-9: baseline 12 → discharge 4. Three of identified four exiles fully unburdened; fourth has been engaged with and is being held by the patient's Self without acute need for unburdening. PCL-5: baseline 41 → discharge 11.

Functioning: high. Risk: low. Relational engagement substantially improved (patient now in a committed partnership). Patient reports 'feeling whole' for the first time in their adult life.

Cooperative termination. Patient and clinician agree the active treatment phase has concluded. Patient is well-equipped to maintain the IFS relationship internally.

Tune-up sessions available on patient's request (no scheduled cadence). Re-engagement encouraged if: a new exile emerges, a current protector becomes destabilized, or any acute clinical issue arises. Patient retains portal access for self-scheduling. Final session [Date].