Trauma Discharge Summary Template
Use this basic template when documenting discharge for clients who received treatment related to trauma symptoms, stress responses, emotional activation, avoidance, or safety related concerns.
Clinical Pearl: Discharge can support trauma recovery by reinforcing safety, stabilization, coping skills, and the client’s increased sense of agency.
Reason for Treatment
Client participated in treatment to address trauma related symptoms, including emotional distress, avoidance, hyperarousal, intrusive memories, negative beliefs, difficulty with safety, or impairment in daily functioning.
Course of Treatment
Treatment focused on stabilization, psychoeducation, coping skills, grounding, emotional regulation, trauma informed processing as clinically appropriate, safety planning, and strengthening support systems.
Progress Made
Client demonstrated progress in identifying trauma responses, using grounding or coping strategies, increasing emotional awareness, reducing avoidance, and improving ability to manage triggers.
Continued Care Recommendations
Client may continue to benefit from ongoing coping skill practice, trauma informed support, safety planning as needed, and continued attention to triggers, boundaries, and emotional regulation.
Discharge Plan
Client is discharged at this time with recommendation to continue using learned skills and seek additional support if trauma symptoms increase or functioning becomes impaired.