Marriage Counseling Cessation Log Form
Use this form to document the end of marriage counseling, including reasons for cessation, key dates, and follow-up needs.
Names of Couple
*
Date Counseling Began
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Counseling Stopped
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Reason for Cessation
*
Goals Achieved
Mutual Decision to Discontinue
One Party Withdrew
Referred to Other Services
Other
Number of Sessions Completed
*
Was a follow-up recommended?
*
Yes
No
Type of Follow-up (if applicable)
Please Select
Check-in Call
Referral to Individual Counseling
Referral to Group Support
No Follow-up Needed
Additional Notes or Comments
Name of Person Submitting Log
*
Role/Position
*
Please Select
Counselor
Case Manager
Administrator
Other
Submit Log
Should be Empty: