Episode Summary

Episode start date:

Episode end date:

Total sessions:

Primary modality:

Diagnosis Search

Current diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Outcome measure (baseline → current):

Reason for Transfer

Stepping up level of care (e.g., outpatient → IOP/PHP/inpatient)

Stepping down level of care (e.g., IOP → outpatient)

Provider change (within practice)

Relocation / Geographic move

Insurance change

Specialty referral (e.g., to psychiatry, substance use)

Additional context:

Clinical Handoff

Current medications:

Active safety plan:

Yes — copy attached / sent

No — not applicable

Treatment summary:

Goals addressed:

Remaining needs / Unresolved issues:

Risk at Transfer

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Risk level at transfer:

No current risk

Low risk — stable

Moderate risk — safety plan in place

Elevated risk — see safety documentation

Coordination

Records sent to receiving provider

PCP notified

Receiving provider contacted

Releases of information signed

Medication reconciliation completed

Receiving Provider

Provider name / Organization:

Contact info:

First appointment:

Aftercare

Crisis resources provided:

Self-monitoring plan:

Re-entry criteria:

Plan and Follow-Up

Plan area	Details
Next visit	When the patient should return and the reason for that interval. Interval:
Orders & referrals	Labs, imaging, or referrals placed at this visit. Orders / referrals:
Patient instructions	Home care, medication or supplement changes, and education provided. Instructions:
Monitoring & safety	What to monitor and when to escalate or seek urgent care. Monitor / escalate:

Episode Summary

Diagnosis Snapshot

Reason for Transfer

Clinical Handoff

Risk at Transfer

C-SSRS

Suicidal Ideation Severity ⓘ

Suicidal behavior (lifetime; most recent date below)

Risk Details

Coordination

Receiving Provider

Aftercare

Plan and Follow-Up

Counseling - Transition of Care Note

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