If the client never signed the Disclosure Statement or the About Me paperwork (example: client attended the intake session, but was not a good fit, so they are being transferred to another clinician), email Jenny (jenny@overcomewithus.com) and ask that you be removed from the client's file. (Include client initials in your email).
Counselors, follow the instructions below on how and when to write a Termination Note. Are you tired of writing notes? Use our AI Scribe.
Ensure that you always use complete sentences, correct grammar, and proper spelling. This is a professional document, and it should be written accordingly. You can use the spell check button at the bottom of the note and download Grammarly to your computer to help you catch grammatical errors.
Choose from the drop-down menu the reason the client is being terminated:
If the client attended an intake session and signed the About Me and Disclosure, but then needs to be transferred to a new clinician, you can write, “Client attended intake session and signed required documentation; however, the client will terminate with this clinician due to (give reason) and be transferred to (Clinician's Name) to continue treatment.”
This is automatically populated from your notes.
This is automatically populated from your notes.
This is where you will write what modality you used with the client during treatment along with the interventions you used with the client. You can look back at previous notes and copy and paste from them.
Example:
The treatment modality used was cognitive behavioral therapy. The interventions used were: Cognitive Challenging, Cognitive Refocusing, Cognitive Reframing, Communication Skills, Exploration of Coping Patterns, Exploration of Emotions, Exploration of Relationship Patterns, Interactive Feedback, Interpersonal Resolutions, Mindfulness Training, Relaxation/Deep Breathing, Role-Play/Behavioral Rehearsal, Structured Problem Solving, Supportive Reflection, and Symptom Management.
This is where you write what the goals of treatment were and then a comment about whether the client met their treatment goals or not (outcome of treatment). At the end, it is important to include a statement about how treatment was terminated (see bold statement).
Example:
The treatment goals were: The client would like to use her strength of intelligence in order to reduce the overall frequency, intensity, and duration of her anxiety so that daily functioning is not impaired. The client will know that change has occurred when she is able to increase her happiness and well-being to an 8 on a scale of 1-10, with 10 being total happiness. The client agrees to use her strength of intelligence in order to describe current and past experiences with specific fears, prominent worries, and anxiety symptoms, including their impact on functioning and attempts to resolve them, and increase her use of effective coping skills to 1-5 skills used daily to be evidenced by decreased anxiety, decreased withdrawal, and decreased worry. The client agrees to use her strength of intelligence in order to identify 1-4 ways her thoughts, physical feelings, and behavioral actions contribute to her anxiety levels and create new thought patterns to replace old thinking patterns to be evidenced by increased ability to cope with feelings of anxiety, increased confidence in self, and increased ability to communicate her thoughts and feelings. Progress will be measured per the client’s reports and clinician observations. The client agrees to use her strength of intelligence in order to verbalize an understanding of the role that fearful thinking plays in creating fears, excessive worry, and persistent anxiety symptoms, and use 3-6 effective coping skills daily to be evidenced by increased understanding of the reason behind her anxiety symptoms, decreased anxiety, decreased withdrawal, and decreased worry. The client agrees to use her strength of intelligence in order to identify, challenge, and replace fearful self-talk with positive, realistic, and empowering self-talk 1 out of every 2 times she becomes aware of the fearful self-talk to be evidenced by an increased ability to cope with feelings of anxiety, increased confidence in self, and increased ability to communicate her thoughts and feelings. Treatment was terminated after 11 months by mutual agreement due to the success of the interventions and the client's confidence in her ability to manage on her own. The client reports successful reaching of all treatment goals.
When the client is terminated, a termination letter must be produced, and in some cases, the client must be given three referrals to continue treatment. A statement must also be made regarding the referrals provided. This communication (i.e., termination letter) with the client should be documented in TN in the client’s file. Create the Termination Letter here: Termination Letter.