· Identifying information of client (i.e., hypothetical name, age, etc.)

· Identifying information of client (i.e., hypothetical name, age, etc.)

· Date initially contacted therapist, date therapy began, duration of therapy, and date therapy will end

· Total number of sessions, including number of missed sessions

· Termination planned or unplanned

· Presenting problem

· Major psychosocial issues

· Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.)

· 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