If we are successful in our work with clients, our professional relationship with them ends. At that time, it is prudent to write a termination letter to formally document the end of that relationship. Here is a list of the things that should be included in that letter.
- Draft a statement that informs the client what termination of treatment is and that emphasizes that it is the client’s responsibility to personally seek further treatment if appropriate.
- Include your client’s name (no “Dear Client” form letters).
- Identify the date when therapy began.
- Note the termination date.
- Relate the primary and secondary diagnosis or, if no diagnosis was give, relate the primary cause for treatment.
- Describe the reason for termination.
- Summarize treatment, including any need for additional services.
- If you feel further treatment is advisable or necessary, make that explicit in your letter.
- List three or more referrals or referral sources, including addresses and phone numbers.**
I wonder what else you think might ought to go in your termination letters?
**This information is taken directly from the book The Portable Ethicist for Mental Health Professionals: An A-Z Guide to Responsible Practice by Barton E. Bernstein, JD, LCSW and Thomas Harsell, Jr., JD.
Hey Tamara,
What are your thoughts on Affordable Care and insurance compensation to private practice folks, counselors, and social workers, ect.? Mike
Hi, Mike! It’s great to find your voice here! Hey, I’m not sure what you are asking. Can you ask it differently?
Thank you so much Tamara. I have never written a termination letter and I see now it should be part of my routine when a client quits attending therapy. You are so helpful!
Welcome back, Linda! And, you are so welcome! I had an attorney tell me once that until that termination letter is written and sent, I could be viewed as the therapist on record. Not something that I really want to have happen 5 years after I’ve last seen a client!
Good stuff. Nice to know what others put in their letters.
Should a diagnosis be part of it though. What about confidentiality?
What is going to be the impact of the ACA on counseling and social work income? Mike
Oh! Yes, get it now! Thanks for the clarification! I wish I could foretell the future, Mike, but I’m waiting to see just like the rest of you guys!
Three years into The Affordable Care Act, I’m really encouraged. We heard so many horror stories predicted about ACA but the truth is that many more people have protections and access to health care than even a year ago. I’m sure that if I am the counselor or social worker that is struggling to make ends meet right now, I might question the potential impact of ACA But, for me . . . it was the right thing to do. Change is often difficult and even scary but we have needed to clean up health care for decades. It may not be perfect but it’s one step in the right direction.
As for the impact on counselors and social workers, I rely heavily on the American Counseling Association and the National Association of Social Workers for monitoring the impact of legislation on the field of mental health. And, the Affordable Care Act is no exception.
I’m curious, though, Mike . . . . How are you and others anticipating the impact on the field?
Mike, here’s how you can set up a gravatar if you are interested. It’s really simple.
I am so glad you addressed this issue of termination letters when client decides to discontinue therapy. However I wanted to ask—how do you suggest providing this termination letter to a client that you have not be able to reach after several attempts to contact (secure message in EHR, email, and attempts to call/leave a brief voicemail) without any returned contact? The only other option that comes to mind is the regular mail however if they haven’t been responsive and in general, I am a bit hesitant to send a termination letter in the mail to the home address on file for privacy reasons and I wouldn’t know if their address changed. Any suggestions? TIA!
M, this is such a great question to ask here because most therapists have been ghosted by a client on more than one occasion.
If this has happened to you, it’s very possible that your client may not respond to your attempts to reach him / her / them.
Hopefully, your informed consent process addressed this issue and you have obtained permission from your client to attempt contact for final closure via mail.
If not, now is a good time to go back and amend your documentation and obtain permission from your current clients to do so.
When clients fail to respond to my attempts to terminate, I send my correspondence (via email or snail mail) in a manner that allows me to securely track delivery and receipt.
For the US Mail, that is called “delivery with certified return receipt.”
As a side note, I do not include my credentials on any envelope I am sending to a client’s street or business address.
Hope this helps, M!
Tamara,
This post was most helpful, thanks for sending it out. I have concerns about providing specific referral sources; names, phone numbers, etc. In the past when I have had instance of terminating with clients it is often because of their failure to hold up to their end of the psychotherapy agreement (outstanding financial balances, no shows/cancellations, etc.) When this happens I consider it a disservice to the other therapists I am referring them to; to send a client that has acted like this. What are you thoughts on referring to websites, CSBs, etc. when terminating with clients?
Hi, Amber! I’m so glad that you bring this up because I think there are many of us who feel that double bind. However, as mental health professionals, our first responsibility is to our clients – even those that leave against medical advice . . . even those who frustrate us . . . even those who cheat us out of money . . . and even those who just quit coming. Unless you believe that they have successfully resolved their treatment goals with you and are not at risk to themselves or others, it is in their best interest and in your own best interest to have done everything that you know possible to do to provide resources for those clients upon termination. It’s also important to remember that we aren’t always the therapist who is a best fit for any given client. It’s entirely possible that they may surprise even themselves by choosing to work differently with the next therapist. 🙂
My recommendation is to do what is in your client’s best interest and in your own best interest. Trust your colleagues’ jundgments to screen for themselves.
HI Amber and Tamara:
Thanks for that exchange – this was an issue I had not thought of, and I loved the response – so simple.
Amy
Oh, Amy! How lovely to see your smiling face this morning! Thanks for dropping in to chat! “. . . so simple.” That’s the funny thing about “staying out of trouble” and “doing what’s right.” Much of the time it is about doing what we are simply supposed to do. And, it’s also interesting how many times I have not done just that . . . and created great big messes along the way!
Thank you for the reminder to “KISS – Keep It Simply Simple”
It’s funny, because while I do termination letters, I had never considered Amber’s good question about how kind it is or isn’t to send them on to someone else if they owe money. I feel like your answer provided a hopeful and practical framework for thinking through our responsibilities to our clients.
Thanks!
Amy
And, I wasn’t really thinking about it in terms of “kindness” so much as “Who have I legally and ethically contracted to help?” It’s my client, not my colleagues.
I’ve certainly been stiffed by my share of clients over the last 30 years but, in hindsight, that has more often than not been about my own issues with money . . . much more than about my clients being bad, money-grubbing people. Yes, they were wrong not to pay me in full; but, I also had / have a responsibility to manage the money / debt in my business in a professional manner. And, truthfully, it took me a good 10 years to recognize and own my own limitation with regards to money . . . and the effect that was having on my practice. Can you say “countertransference?”
Hi Tamara,
I really enjoyed this post and realized the benefit of a termination letter, not to mention the risk reduction! I plan to implement this right away. Thanks so much for bringing it up.
Hi, Melany! I do love hearing from you guys in Texas! Thank you for taking a moment to drop in! So glad you find this post to be of use and hope you’ll let me know if you see something that I’ve left out of the letter!
I hope you’ll be back often to chat here at Private Practice from the Inside Out!
Another great post, Tamara. I am curious what you do in those situations where therapy has come to a more subtle end, i.e. the cancelling and not rescheduling type. Do you wait a certain amount of time? Do you reach out and a non-response signals termination?
I usually reach out. Sometimes clients reschedule and sometimes there’s a non-response. I do encourage discussing termination in my intakes. Would love your thoughts!
Allison, this is such a great question and one I certainly bumbled early in my career. When I have a client who “just disappears,” I deal with that client based on my previous knowledge of that client . . . . If she is a new client or a client that I believe to be somewhat fragile, I will call within a week or so to check on her and see if she might like to reschedule with me or would like a referral to another therapist who is a better fit. If when I don’t actually get to speak with the client, I will call back for a couple of weeks (just once each week). In my last message (assuming I don’t reach her and / or she does not return my calls), I typically say “I don’t want to be intrusive but I also don’t want you to think that I’m not concerned about you or wanting to support you. I won’t be calling you again but if there is anything I can do to work with you or to refer you to another professional, feel free to let me know.”
I encourage therapists to create a policy for their practice that charts are routinely closed after X amount of time without any contact from a client. The time frame can be as short as a month or as long as a year. One way to establish that time frame is to think about how long you want to be the therapist of record without seeing a client; a different way would be to consider how long you want a client to be away without requiring them to complete new paperwork.
I’m sure that there are others who can also contribute to this conversation. Care to share?
Tamara, I have never used termination letters before, but I love the concept. Thanks!
Hi, Andrea! And, welcome to Private Practice from the Inside Out! So happy to introduce you to them. What is it you do and where are you?
Hi. I just found this post and it’s very helpful. I haven’t used a termination letter in the past. Is there something I could do with old cases/files where contact has ended – either due to no shows and non response, or successfully meeting goals – to indicate that treatment has ended and that I am no longer the therapist for those clients? I feel like it would be weird to send a letter at this point after months or even years have passed. Thanks for any advice.
Hmmm. Sara, that’s a really great question that many of us have had to consider along the way. Assuming that your state and / or ethical requirements don’t dictate it, I think it becomes a judgement call for you with several things to consider. If you have your client’s permission to contact them, then you could – even a year later write a letter that states something like . . . “It is my policy to write a formal letter of termination to clients when I have had no professional contact with them for 12 consecutive months . . . . ” However, what would be even better is to create an office policy going forward that you can consistently implement.
The bottom line is that when we learn to do better, we do better. 🙂
By the way, Sara – where are you (geographically) and what is your practice focused on?
Our practice client agreement states that we are no longer your provider if we haven’t seen you for 60 days. Do I need to send termination letters to anyone I haven’t seen in more than 60 days?
I understand it would be a courtesy, I am trying to clarify the legal and ethical obligations. Our practice is in Missouri.
Hi, Kerry! Welcome!
I am not an attorney and I am not familiar with the laws for practicing in Missouri.
However, what I do understand from training provided by my own liability insurance companies is that it is a best practice to minimize your own liability to send a letter of termination to clearly note that you are not longer responsible for the clinical work this client is receiving.
Some states do require a letter of termination but not all do.
Thanks for asking this question!
I hope you’ll be back often to join the conversations!
Thanks for your reply. I do plan to implement a practice policy going forward – and I can have current clients sign it as well. So it sounds like it is a judgement call for former clients from over a year ago? I have looked long and hard for a state policy (Michigan) or an NASW policy, and I can’t find anything about liability related to a lack of formal termination documentation. Any idea where I might find that info?
I’m in Michigan and my practice is focused on women’s issues.
Sara, thanks for filling me in on your practice a bit! I’m always happy to have a Michiganders in the mix here at Private Practice from the Inside Out!
it’s a judgement call only if you are able to determine that there is no ethical or legal guidelines or standards of practice that dictate otherwise. It sounds like you’ve already done some of the research on this . . . . The only other place that I would suggest you check is with any licensing board for your discipline.
With my agency, we do an aftercare plan. We include most of the same information as a termination letter, but I try to highlight the most important information, such as names and phone numbers of community resources they are currently involved with, and emergency resources in their area. While I do not put this in the aftercare plan, I always make sure they know they can still call me. It is reassuring for them to know the relationship is not completely severed, even though it is terminated on paper. If they ask for information above and beyond what I can provide after the case is closed, I explain to them what my limitations are (and this has only happened twice in my 15 years in the field).
However, if a client is unsuccessful, we do not provide them with anything, and I am wondering if, ethically, I should be doing this, even if the agency does not require it.
Hi, Michelle! Welcome back! So “unsuccessful” can mean a lot of things and I’m not sure what you mean by it. Care to explain?
What I know is that agencies often have rules about what you can and cannot do / should and should not do with current and past clients. So, that’s the first place you need to go to see if they might prohibit such contact. I suspect that your aftercare plan actually takes the place of a termination letter for most of your clients. However, you also have an ethical responsibility to the remainder of your clients that you describe as “unsuccessful.” Whatever that means, as best I understand it best practice would dictate that you attempt to contact those clients to provide them with additional support i.e. referrals to other agencies / professionals, encouragement to return to services at your agency, possibly support groups in the area, and even literature / audio materials related to their particular concerns.
I know it’s difficult sometimes to take the time and make the effort with clients when it can feel like they have rejected your services; however, that is just a good reminder of the need for each of us to maintain good boundaries and not personalize the responses – good or bad – that any given client my have.
This is such a great post and discussion! I have a client that I need to actually “fire.” She has been screaming obscenities at both me and her husband in the last four sessions (I have been seeing them for almost a year.) She refuses to stop, and her behavior is impacting other tenants in my building. She has tremendous difficulty with emotional regulation and I fear the repercussions of an official termination letter. Any thoughts?
Hi, Lori! Welcome to Private Practice from the Inside Out and thank you for sharing this situation. I do have several thoughts but am wondering, first, what type of repercussions you might be most worried about. Care to share?
Sure! I worry about a certain amount of retribution (this is a BPD client with a history of severe trauma) as a knee-jerk response to feeling rejected. Anything from keying my car, writing horrible online reviews – maybe even violence (she has a criminal hx as well).
OK, Lori, now I get what you’re concerned about. I wasn’t sure if you were concerned about legal implications or a client’s reactions to termination. And, I’ve lived through what you’re worried about.
I keep thinking I need to address this in a proposal for a workshop at one of the conferences I attend. I think though that I’ll start by taking this back up front to a full blog post. Hope you don’t mind, Lori! And, if you’ll let me know where you are and what you do, I’ll be happy to tip my hat your direction and mention that in the post, too.
I’ll try to get this cued up for next week. I hope you’ll be back to continue the conversation there!
Sounds great Tamara. Thanks. I’m an LMFT and LMHC in private practice in Bellingham, Washington.
The situation continues; I haven’t written the letter yet and the client full-on refuses to accept ending the therapeutic relationship. I’m feeling pretty trapped!
Ohhh, I’m so sorry you’re going through this, Lori! Working on the post today.
Bellingham! What a lovely little town! My sister and I were just there last July. I so love coastal Washington (Oh, OK, and Snohomish, too:)
Here’s the new post, Lori – How to Terminate Therapy with a Client. Happy to continue the conversation there!
I have a concern with sending sensitive information like diagnosis and reason for initiation of services for fear of it getting into the wrong hands. Does sending information certified cut down on that?
Hi, Daphne! Welcome back! You are right to be concerned about confidential information ending up in the wrong hands. However, you need to remember that your client has a right to that information and the ability to share that information with others.
In the United States, “certified mail” only verifies that you actually sent something through the US mail. It does not verify that it was received or by whom. Even “registered” mail only verifies a chain of custody. “Return receipt requested” actually proves who received your letter.
I’d love to see a sample termination letter if you have one you can share?
Stacie, because this post is older, it’s likely not many therapists will see it. A better way to obtain samples might be to post your request on therapists’ email discussion lists, Twitter, LinkedIn, and Facebook groups.
If you have a specific question, I’m happy to try to answer it.
Tamara,
Can you send a termination letter via email if you don’t have a current address? For example, client stopped contacting me for six months and now I want to send a termination letter?
Thanks!!!
Briana, this is not a good idea. Things to consider – Do you have the client’s permission to contact her by email? Is your email HIPAA compliant? How are you going to prove that your client receives your notice? I recommend that you send it by certified mail with signature confirmation.
Yes, that would be how I usually send them. However, in the instance of not having an address would you just not send a letter at all? Yes, email/text communication is covered in my service agreement.
But, Briana – is it SAFE and CONFIDENTIAL? If not, I would err on not sending it – unless your state dictates something different.
Hey Tamara, I know this is an older post, but I had a quick question.
My office has an online registration system where clients can register as a “new patient” without contacting me first.
As a result, I have some clients showing on my caseload with whom I have never met, and some who have never responded at all to my attempts to contact them. For these types of clients, would you recommend still sending a formal letter of termination, or can I just close the files since I have never met with them? Does my ethical/legal responsibility begin once I start treatment, or is it as soon as they register with me? Any insight would be appreciated!
Hello
What is the best way to send a termination letter to a client if they just quite seeing you and you can not do it in person?
His, Veronica! Thanks for dropping in!
It’s important when you’ve been ghosted by a client, to properly close out your file and send that termination letter.
The way you should send it in the United States is by Registered Mail with a Return Receipt.
This is a secure way to send your letter and verify that it was received.
Here is an article that you may find useful talking about the difference between Certified and Registered Mail with a Return Receipt.
I want to seek help
What type of help are you needing to build your private practice?
Hello Tamara,
I truly appreciate your blog and find your perspective enlightening. Thank you for your hard work and guidance. I am in private practice as an LCSW in Maine, Delaware and Florida. I practice out of the country for a portion of the year and would not be able to send certified mail. Also, I appreciate having all clients documents sent through and kept in my online Client Portal. I wonder if sending a letter via my Client Portal, as I do with all other client related documents, is an adequate approximation of what you describe? I get a time stamp for when documents are delivered and can see if they have been viewed.
Thank you for considering my question.
Jennifer
Hi, Jennifer! What a great question . . . and honestly, I’m not sure.
I’m going to make an educated guess here and say I think it would because the goal is for your to be able to prove that you sent the letter.
Just make sure that you back up your online “proof” (including time stamp and proof of viewing) – and don’t rely on whatever the company is that your client portal is supported by to do that.
And, make sure your clinical record also has a copy of the documents, note regarding date and time stamp and status of it having been received and viewed.
That’s just about as good as you can do.
I appreciate you following my work and dropping in here to chat!
Nice
Hi Tamara,
Could this be sent in an email?
Can it? Should it? No.
You need to have proof that you sent it and proof that it was received – by your client and not anyone else.
Is there a reason you do not want to send this by mail?
Perhaps I am missing something?