A discharge letter providing an overview of a client / patient’s complete treatment. It is appropriate to use if a clinician has finished their therapeutic relationship with a client / patient and is writing a detailed letter or report to another health professional, such as a referring GP.
The letter will integrate information from previous NovoNote sessions and NovoPsych psychometric assessments, if available.
Re: Client’s Full Name; Client’s Date of Birth.
Dear Dr Referring Clinician’s Name,
Thank you for referring Client’s Name, who I have seen on specify type and length of treatment and now discharge from my care.
Presentation
Concise summary of client’s background, initial presenting issues, and treatment goals. Include relevant information about circumstances, diagnoses, medical history, occupation, living arrangements, social support, and trauma history. Summarise initial bio-psycho-social formulation and note any significant changes during treatment.
Treatment
Summary of the treatment provided including dates, frequency, therapeutic modality, interventions used, homework activities, treatment outcomes, client engagement, and therapeutic alliance. Include medication information if applicable.
Psychometric assessments
List of completed assessments with dates and summarised results, in chronological order with most recent first.
Coping skills
Description of client’s strengths, positive coping skills, successes during treatment, positive character aspects, and protective factors. Discuss relevance to current and future situations.
Recommendations
Recommendations for future treatment and management with rationale for each suggestion.
Reason for discharge
Note reason for ending treatment and any plan for re-engagement if applicable.
Should you have any further questions regarding Client’s name, please feel free to contact me.
Sincerely,
Clinician Name
Clinician Profession
Practice Name
Re: Michael Thompson; DOB: 15/03/1985
Dear Dr. Wilson,
Thank you for referring Michael Thompson, whom I have seen for 12 sessions of cognitive behavioural therapy and now discharge from my care as we agreed he has now reached his treatment goals.
Presentation
Michael presented with depression and anxiety following a workplace back injury six months prior to referral. His symptoms included low mood, sleep disturbance, social withdrawal, and excessive worry about his career future. Michael was working on modified duties and expressed concerns about returning to his construction manager role. His goals included improving mood, developing pain management strategies, and building confidence for returning to full duties.
Treatment
Michael attended fortnightly CBT sessions between February and May 2025. Treatment focused on cognitive restructuring of unhelpful thoughts, behavioural activation, sleep hygiene, and pain management strategies including pacing and mindfulness. He engaged well in therapy and consistently applied strategies between sessions.
Psychometric assessments
Depression Anxiety Stress Scales – Short Form (DASS-21). The DASS-21 is a self-report measure designed to assess the negative emotional states of depression, anxiety, and stress. Results (10/05/2025):
Interpretation: Michael’s scores show significant improvement from initial assessment when depression and stress were in the severe range and anxiety in the moderate range. These improvements align with his self-reported functional gains.
Coping skills
Michael has developed effective strategies, including challenging negative thoughts, regular pleasant activity scheduling, mindfulness for pain management, and assertive communication. He has reconnected with social supports and resumed modified participation in his weekend cricket team, which has improved his mood and confidence.
Recommendations
I recommend Michael continue practising the cognitive and behavioural strategies during his transition back to full work duties. Given his good progress, ongoing psychological therapy is not required at this time. A brief follow-up in 3-4 months may be beneficial to ensure maintenance of gains, particularly if there are setbacks in his physical recovery.
Reason for discharge
Michael’s physiotherapist continues to work with him on physical rehabilitation, with a plan to transition to a self-managed exercise program next month.
Michael has been discharged and understands he can contact your practice for re-referral if needed.
Should you have any further questions regarding Michael Thompson, please feel free to contact me.
Sincerely,
Dr. Rebecca Taylor
Clinical Psychologist
Melbourne Health and Wellbeing Centre
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