Social Work Evaluation and Termination Form
Complete this form to assess case progress and document termination details for social work cases.
Case Reference Number
*
Client Age Group
*
Please Select
Child (0-12)
Adolescent (13-17)
Adult (18-64)
Older Adult (65+)
Primary Reason for Case Termination
*
Goals Achieved
Client Disengaged
Referral to Another Service
Service No Longer Needed
Other
Client Engagement Level at Termination
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Overall Progress Toward Case Goals
*
No Progress
1
2
3
4
Goals Fully Achieved
5
1 is No Progress, 5 is Goals Fully Achieved
Satisfaction with Services Provided
*
1
2
3
4
5
Assessment of Key Domains
*
Rows
Significant Improvement
Some Improvement
No Change
Declined
Housing Stability
1
2
3
4
Employment/Education
5
6
7
8
Mental Health
9
10
11
12
Physical Health
13
14
15
16
Social Support
17
18
19
20
Recommended Follow-Up Actions
No further action required
Referral to community resources
Periodic check-ins
Other
Comments or Additional Notes
Evaluator Name and Role
*
Submit Evaluation
Should be Empty: