Identifying information of client (e.g., hypothetical name and age)
Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end
Total number of sessions, including number of missed sessions
Whether termination was planned or unplanned
Presenting problem
Major psychosocial issues
Types of services rendered (e.g., individual, couple/family therapy, group therapy)
Overview of treatment process
Goal status (goals met, partially met, unmet)
Treatment limitations (if any)
Remaining difficulties and/or concerns
Recommendations
Follow-up plan (if indicated)
Instructions for future contact
Signatures