Discharge Notice Form printable pdf download

Noeticus Counseling Center

and Training Institute

™

Innovative Approaches to Counseling and Change

DISCHARGE NOTICE

Client Name:

________________________________________________________________

Record #:

________________________________ Date: _________________________

Address:

________________________________________________________________

Phone Number: ________________________________________________________________

Dear ___________________________________________,

In accordance with the discharge plan established by you and your therapist, or in evaluating

your current records (including your initial goals for therapy, progress notes, attendance and

participation in therapy, and therapist availability) it has been determined that you are no longer

utilizing our services for one or more of the reasons listed below:

❏ Client discharged as planned

❏ Client moved or left area

❏ Client no longer making appointments (longer than 2 months since last appointment)

❏ Client missed more than two appointments

❏ Client terminated against therapeutic advice (ATA)

❏ Client referred for other services: ____________________________________________

❏ Other: __________________________________________________________________

At the time of your discharge your outstanding balance is: $ ______________________________

At the time of your discharge the amount of any refund is: $ _____________________________

If you feel this Discharge Notice is premature or you desire to continue receiving services, please

contact your therapist immediately. Please note that arrangements can be made for outstanding

balances and this should not influence your decision to discontinue receiving services. If we do

not hear from you within the next two weeks (fourteen calendar days) of this letter, we will

assume you are in agreement with your discharge.

If you did not have the opportunity to discuss a therapeutic discharge with your therapist before

receiving this letter, you are highly encouraged to do this. As stated in the Initial Consent for

Services Form you completed at the beginning of your therapeutic relationship, having a clear

and respectful closure is a significant element of the therapeutic process and serves to maintain

an important connection and resource for you in the future. Additionally, practicing direct and

honest closure in your therapeutic relationship is an excellent way to practice this skill for other

relationships. Here is the text from the Initial Consent for Services Form for your reference:

- Please See Reverse Side –

190 East 9

Avenue, Suite #290 ❖ Denver CO 80203-2744 ❖

303-399-9988 Phone ❖ 303-399-9977 Fax ❖ 855-399-9988 Toll Free ❖

Discharge Notice Form