Free Discharge Summary Template

What is a discharge summary?

A discharge summary is a clinical document that concludes a course of treatment and provides a comprehensive overview of the therapy or medical episode. When a client completes therapy, transitions to a different level of care, relocates, or when a provider-client relationship ends, a discharge summary documents what was accomplished, how the client has improved, what diagnoses or formulations guided treatment, what strategies or skills were developed, and what recommendations the clinician makes for ongoing support or follow-up care. Discharge summaries serve multiple purposes: they summarize the clinical episode for the client's own records and future reference; they communicate key clinical information to other providers who might continue care; they document treatment outcomes for insurance companies; they provide a roadmap for self-care and relapse prevention; and they create a professional closure to the therapeutic relationship. A well-written discharge summary reflects the entire course of treatment and positions the client for continued success after therapy ends.

What's in this template

This discharge summary template includes:

• Client & Treatment Episode Information: Client name, dates of treatment (start and end), total number of sessions, treatment setting, clinician name and credentials
• Reason for Treatment & Presenting Problems: Chief complaints at intake, diagnosed conditions, referral source, initial treatment goals
• Treatment Course Summary: Brief chronology of therapy arc (early sessions, key turning points, progress phases), adjustments to treatment approach, major themes or breakthroughs
• Diagnoses & Clinical Formulation: Primary diagnoses and any comorbid conditions treated, case formulation explaining the client's difficulties and therapeutic work, progress on each diagnosis
• Treatment Modalities & Interventions Used: Therapy types used (CBT, psychodynamic, motivational interviewing, etc.), specific techniques or modules, any adjunctive treatments (medication management, psychiatric consultation, referrals)
• Progress Toward Goals: Original treatment goals, degree to which each goal was achieved, measurable improvements in symptoms or functioning, client's own assessment of progress
• Symptoms & Functioning at Discharge: Current psychiatric symptoms, mood and anxiety levels, sleep, appetite, concentration, functional ability in work/school/relationships; comparison to intake baseline
• Client Strengths & Coping Skills Developed: Identified strengths and resilience factors, specific skills or coping strategies learned in treatment (e.g., exposure techniques, thought records, distress tolerance skills), insight gained
• Medications: Current psychiatric medications and dosages, medication changes during treatment, adherence and side effect management, ongoing psychiatric management needs
• Reason for Discharge: Completed treatment goals, client relocation, transfer to different provider or level of care, insurance limitations, client choice, clinical recommendation for step-down
• Recommendations for Ongoing Care: Continued psychiatric medication management or primary care coordination needed, therapy recommendations (ongoing, future, or as-needed basis), lifestyle recommendations, warning signs to monitor
• Relapse Prevention Plan: Early warning signs of symptom return, specific coping strategies to use, when to reach out for support, crisis resources and safety planning
• Follow-up & Referrals: Referrals to other providers or services, recommendations for support groups or community resources, schedule for follow-up appointment or check-in if appropriate
• Closure & Best Wishes: Professional closure acknowledging the client's work and growth, encouragement for continued progress

When to use this template

Use the discharge summary when:

• Completing a course of therapy or treatment with a client
• A client is moving or transferring to a different provider
• Treatment has reached a natural endpoint or transition point
• Stepped care or level-of-care changes occur
• Transferring care to another discipline (e.g., therapist to psychiatrist for ongoing medication management)
• Creating a record for the client's personal files or for sharing with other healthcare providers
• Documenting completion of a specific treatment episode for insurance or licensing purposes

This template is used across all mental health and medical settings: private practice, clinics, hospitals, community mental health centers, substance use programs, and residential treatment facilities.

How to use the template with Scriber

Record your discharge session with the client with consent and Scriber transcribes the session discussion. Rather than writing a lengthy summary from memory after the session, you have a transcript capturing what the client reflected on, improvements they identified, skills they valued, and what they're planning going forward. Use the transcript to draft the discharge summary: extract the client's own report of progress, synthesize the treatment course you documented in prior notes, craft recommendations based on the discharge conversation, and ensure the summary honors both the clinical work done and the client's perspective. This keeps your focus on the meaningful closure conversation while AI handles transcription.

Download (free)

This template is available as a printable PDF and editable DOCX file. Customize it to match your treatment setting and approach, adjust sections to fit your typical episodes of care, and use it as a standard form for all client discharges.

[Download PDF]

Related templates

• Referral Letter Template — Template for referring a client to another provider
• SOAP Note Template — Standard progress note format for ongoing documentation