End-of-therapy summary: template, structure and example

An end-of-therapy summary is the note that closes a patient's file. On one page, it sets out why they came, what was worked on, what changed, what remains fragile and what was agreed for the future. It is written when therapy stops, whether by mutual agreement, at the patient's initiative or because a referral is needed.

It serves the psychologist first, if the patient comes back two years later. It is also the basis for a letter to a doctor or colleague, and it shows continuity of care. This template is for psychologists in private practice or institutions, whatever their approach.

What the end-of-therapy summary is for

A file of several dozen sessions is hard to reread. The summary gives the essentials in a few minutes. It lets you resume interrupted therapy without starting from scratch, write a letter quickly if the patient asks, and hand over to a colleague in good conditions.

For the practitioner, it is also a moment to step back. Rereading the original reason for coming and measuring the distance travelled helps you see what worked, and sometimes what was never addressed.

When to write it

• At the end of therapy agreed together, after the last session.
• When the patient stops on their own or does not come back, after a period you set (for example after a follow-up message with no reply).
• When you refer the patient to another professional or service.
• When you stop practising or move to a different practice.

The ethical and legal frame

The points below describe the French framework. In Belgium and Switzerland, refer to the rules of your own country.

Continuity and referral

The French code of ethics for psychologists (2021 version) provides that psychologists may refer people to other professionals when they see fit (article 5) and, where relevant, inform them that they may consult another practitioner (article 9). When they stop practising, they try to ensure continuity, and records may be handed over or destroyed using procedures that guarantee confidentiality (article 19). The summary is the natural tool for this handover.

Storage and confidentiality

The code asks psychologists to collect, sort and archive their notes in a way that protects privacy and professional secrecy (article 23), and to protect data from their work whatever the medium (article 6). It does not set a retention period. Depending on your setting (private practice, institution, funded scheme), find out which period applies and state it in the information you give patients.

Sharing with a third party

If the summary is used as the basis for a letter, article 15 of the code requires the person's assent or prior information, and limits psychological content to what is necessary. Under the French Mon soutien psy scheme, the Assurance Maladie states that after the last session the psychologist may send the doctor an end-of-care report, with the patient's agreement.

Who can read it

For health information held by a health facility or health professional, the patient has a right of access under article L1111-7 of the French public health code. In private practice, they have at least the right of access to their personal data under the GDPR. Write the summary so the patient could read it, with no judgement and no unnecessary information about third parties.

The structure, section by section

1. Identification and period

Patient's initials or identifier, age, dates of first and last sessions, number of sessions, frequency, setting (private, funded scheme, institution) and who referred the patient, if anyone.

2. Reason for consulting and request

What brought the patient, in their words if possible, and what they hoped for. This is the reference point for the whole summary.

3. Situation at the start

Main difficulties, relevant life context, rating scale scores if measured, current treatments and other care.

4. Goals and approach

The goals agreed and the approach used, in two or three sentences.

5. Course of therapy

The main stages, key themes and events that shaped the work. Keep to the highlights, not session detail.

6. Change and state at the end

What changed compared with the start, goal by goal. End scores if you have them. What remains fragile and the warning signs to watch for.

7. Reason for and manner of ending

Mutual agreement, patient's decision, referral, interruption by the practitioner. How the ending was prepared and what the patient said about it.

8. Referral and recommendations

Professionals or services suggested, contact details given, recommended resources, the option to get back in touch.

9. Information shared

Whether a letter was sent, to whom, with what agreement and when.

Worked example

The following example concerns a fictional patient.

Identification and period. Mr D., 42. Private practice, 6 January to 30 June, 18 sessions, weekly then fortnightly. Came on his own initiative, on his GP's advice.

Reason and request. Exhaustion and irritability since a reorganisation at work. "I don't recognise myself, I shout at my children." Wants to feel calmer and to work out whether he should change jobs.

Situation at the start. Short sleep, tired on waking, stopped sport, frequent conflict at home. PHQ-9 score of 14. No suicidal thoughts expressed. No current treatment.

Goals and approach. Understand what keeps the exhaustion going, rebuild a recovery routine, clarify his position at work. Integrative approach, mainly cognitive behavioural.

Course of therapy. Early sessions focused on sleep and returning to physical activity. Then work on his high standards for himself and his difficulty turning down extra work. In April, a meeting with his manager and a move to part-time on one project. Final sessions on relapse prevention.

Change and state at the end. Better sleep, running twice a week again, less conflict at home by his account. PHQ-9 score of 5. Still sensitive to periods of heavy workload. Warning signs identified with him (early waking, dropping sport, irritability).

Ending. Ended by mutual agreement, prepared over three sessions with gradually wider spacing.

Referral and recommendations. No referral needed. Mr D. knows he can get back in touch if he notices the warning signs.

Information shared. Mr D. does not want a letter sent to his GP for now.

Common mistakes

• Not writing a summary when the patient stops without warning, which is when it is most useful.
• Copying session notes instead of summarising.
• Describing the end state without comparing it with the original reason for coming.
• Forgetting to record what remains fragile and the warning signs.
• Sending the summary as it is to a doctor, when a shorter letter focused on coordinating care is more suitable.
• Not stating whether the patient was referred and to whom.

Save time with Delta

Delta is the clinical assistant for mental health and allied health professionals. During the session, Delta transcribes what is said. You can also dictate your observations after the session and add written notes. Delta generates the report for each session (short summary, detailed summary, topics for the next session) and updates the patient record, with the progress summary and tracked goals. By the end of therapy, that summary and those goals are already up to date. Delta also drafts letters, certificates and assessment reports tailored to your profession. Data is hosted in France with an HDS-certified provider, the patient's name and identifying details are pseudonymised before the AI, no audio file is kept and data is never used to train a model. Discover Delta.

Further reading

• Psychologist letter to a GP, template
• Child and adolescent session note template
• Note-taking software for psychologists
• All clinical document templates

Sources

• French code of ethics for psychologists, 2021 version
• Ameli.fr, Mon soutien psy, end-of-care report
• CNIL (French data protection authority), the right of access
• Service-public.gouv.fr, access to medical records