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Dean Hope Center For Educational & Psychological Services Teachers College, Columbia University Box 91, 525 West 120th. Street, New York, N.Y. 10027-6696 Tel. (212) 678-3262 Fax. (212) 678-8105 Dinelia Rosa, Ph. D., Director Adult Termination Summary Client: _________________ Sex: _____ Date of Birth: __________________ Age: _______ Duration of Services: Date completed: _____________ Date of last session: __________ Student: __________________ ________________________________ The TERMINATION SUMMARY is the one report most likely to be read by someone in the future, as it is the one usually sent out when the CEPS gets a request for old records. Think of the person who may be working with your client in the future as your audience and review the entire course of your work with the client. Reason for referral: As per described in the Intake. Description of client: Describe the self-presentation of client during intake and at present. Describe any significant changes. Chief complaint: Describe briefly the original complaint in client’s own words and its change throughout the course of treatment to the present. Client history: Knowing now all that you have learned about the client, summarize the most relevant factors, facts and events in the client’s developmental, family, medical, social, educational and work history. If you are going to describe changes, you must summarize the original situation described during intake to help the reader that may not have the intake to review. Presenting problems and stressors Current environment Alcohol and substance abuse Developmental and social history Gestation, infancy, childhood, and adolescence Psychosexual history Educational/Vocational history Social history Criminal/Legal history Family history Family composition and significant history Family psychiatric and medical history Medical history Multicultural evaluation Language Migration history, if applicable: Cultural and racial identity Spiritual/Religious history Acculturation Summary of clinical impression and course of treatment: Briefly summarize objective aspects of the service provision over the entire course of the treatment covering matters such as frequency of sessions, client’s response to treatment structure (e.g. fees, appointments), and summarizing material found in the service delivery section of earlier reports. Briefly review the issues and problems that were of main concern at each phase of the treatment process, restate material in the service plan, and focus sections of earlier reports Provide final cultural formulation (Please refer to the DSM-V). If client provided a cultural explanation of his/her presenting problem, indicate if there were any changes in that understanding. If client did not provide a cultural explanation at the beginning, but did later on, describe any changes. Were there any changes in the predominant idioms of distress through which symptoms or the need for social support were communicated, the meaning and perceived severity of the symptoms in relation to norms of the cultural reference group? Provide final Clinical formulation and impressions. Summarize your understanding of the nature, causes and psychodynamics of the client’s problem; state your assessment of the client’s motivation and expectations for treatment; describe the client’s strengths and weaknesses; integrate your own insights and relevant data from the preceding sections in this section. Describe progress and changes in all of the above. Include all major diagnostic and treatment considerations that were part of the work with the client. Include any changes in defensive style and coping mechanisms. Provide supportive reasoning behind the diagnosis. Conclude with a discussion of the termination. Why is the case being terminated at this time? What are the client’s feelings about termination? Mental Status Examination: Provide MSE at the time of termination. Appearance and behavior Speech Mood and affect Thought process Thought content Sensorium and cognitive functioning examination: Memory Judgment Insight Diagnosis: Whether or not the diagnosis has changed, enter a full, DSM-V diagnosis here, using the format described in the Intake Report sample. Original DSM-V Diagnosis: DSM-V moved to a non-axial format. Make full DSM-V diagnosis, using format shown. Do not use “No Other Specified,” (NOS). Instead use “Other Specified,” or “Unspecified.” Main Diagnosis: _____.____ _____________________________________ Secondary Diagnosis (If applicable):_____.____ ___________________________ Personality Disorder: (If applicable): _____.____ ___________________________ In a separate paragraph and in a narrative way describe the psychosocial and environmental problems that might be contributing to the diagnoses described above (Old Axis IV). Final DSM-V Diagnosis: DSM-V moved to a non-axial format. Make full DSM-V diagnosis, using format shown. Do not use “No Other Specified,” (NOS). Instead use “Other Specified,” or “Unspecified.” Main Diagnosis: _____.____ _____________________________________ Secondary Diagnosis (If applicable):_____.____ ___________________________ Personality Disorder: (If applicable): _____.____ ___________________________ In a separate paragraph and in a narrative way describe the psychosocial and environmental problems that might be contributing to the diagnoses described above (Old Axis IV). Final Recommendations and Disposition: Your last words as you look ahead! What is the client’s prognosis? What work remains to be done? Include clinical and multicultural aspects. What is left to say about the client? What was discussed with the client in terms of future recommendations and disposition? How did client feels about disposition plan? What might be helpful to a future professional who someday may be reading your report? Please indicate: Continue in CEPS with _____ Doc. Student ____ Masters Student Refer to CEPS for other services: _________________________________________________ Refer out of CEPS _____________________________________________________________ Trainee’s name: ___________________ Supervisor’s name: _________________________ Trainee’s signature: _________________ Supervisor’s signature: _____________________ Date: ____________ Date: ______________________