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Sam Barnes - Termination Summary

Sam Barnes has completed his treatment for social anxiety, showing significant progress in managing his symptoms and improving his confidence. The termination of services was a mutual decision, with referrals provided for future support if needed. His primary diagnosis is Social Anxiety Disorder, with additional differential diagnoses noted.

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49 views2 pages

Sam Barnes - Termination Summary

Sam Barnes has completed his treatment for social anxiety, showing significant progress in managing his symptoms and improving his confidence. The termination of services was a mutual decision, with referrals provided for future support if needed. His primary diagnosis is Social Anxiety Disorder, with additional differential diagnoses noted.

Uploaded by

LangstonEG
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Student Name: Monica Morris Date:

02/20/2025

Final Session/Termination Event Summary Template


Client Name: Sam Barnes Date:
02/20/2025

This form can serve as the Progress Note to document the last session by
using either a DAP or SOAP format below:

Main reason for termination of services:


X The planned treatment was completed. - Sam has made significant progress in
addressing his social anxiety and avoidance behaviors. He has successfully engaged in
structured exposure exercises, cognitive restructuring, and self-esteem-building strategies.
He is now better equipped to manage social interactions and has reported an increase in
confidence when initiating conversations.
The client refused to receive or participate in services.
There was little or no progress in treatment.
This is a planned extended pause in treatment.
The client was referred for services elsewhere.
The client was referred to:
Other:

Source of termination decision:


Client initiated. Therapist initiated.
X Mutual decision. - Sam and the Other:
therapist have agreed that his goals
have been met, and he has developed
the necessary coping skills to continue
progress independently. However,
referrals have been provided should
he seek additional support in the
future.

ICD 10 #, Diagnosis and differential diagnosis(es) with specifiers:


1. Primary Diagnosis: F40.10 - Social Anxiety Disorder
2. Differential Diagnoses:
 F41.1 - Generalized Anxiety Disorder
 F60.7 - Avoidant Personality Disorder

Presenting Problem(s):
1. Severe anxiety and avoidance behaviors in social situations.
2. Persistent negative self-perceptions related to being judged or seen as
awkward.
3. Loneliness and difficulty forming meaningful social connections

Goal(s) of Therapy:
1. Develop confidence in initiating and maintaining conversations in social
situations.
2. Improve self-esteem by challenging negative thought patterns and
reinforcing positive self-perceptions.

Rv. Spring 16 1
3. Establish and maintain meaningful social connections through structured
engagement activities and skill-building exercises.

At least 3 Referrals:
1. Local Social Skills Training Group – To continue structured social
exposure exercises in a supportive environment.
2. Primary Care Physician – For routine check-ups and to monitor overall
mental well-being.
3. Therapist Referral List – Should Sam wish to seek additional therapy in
the future for continued self-improvement.

Counselor-in-training Signature Supervisor Signature

Rv. Spring 16 1

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