Therapeutic Relationship Termination Form
Record the administrative details of closing a therapeutic relationship.
Client Name
*
First Name
Last Name
Therapist or Counselor Name
*
First Name
Last Name
Relationship Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Ending
*
Client decision
Therapist or practice decision
Goals completed
Transfer to another provider
Other
Final Session Status
Completed
Scheduled
Not applicable
Were referrals or other resources offered?
Yes
No
Not applicable
Administrative Notes
Submit Form
Should be Empty: