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Psychotherapy Termination Note
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Reason for Termination:
• • •
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Chief Complaint
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Most Recent Diagnosis
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Axis I
• • •
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Axis II
• • •
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Axis III - General Medical Condi
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Axis IV
• • •
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Axis V - GAF
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GAF Description
• • •
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Primary Diagnosis
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Treatment Modality and Intervent
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Treatment Goals and Outcomes
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Referrals Made to:
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