Case Closure and Discharge Summary Form

Formally closes a client case by summarizing services delivered, goals achieved, reason for closure, and post-discharge plan. Used by case managers in nonprofit and social services settings to complete record closure.

Client and Case Identification

• Client ID / Case Number
  Enter the unique client or case identifier from your case management system. Do not enter Social Security Numbers or other sensitive identifiers here.
• Client First Name
• Client Last Name
• Program / Service Line
  Select the program under which this case was managed.
• If 'Other', specify program name
• Date Case Was Opened
• Date of Case Closure
• Case Manager Name
• Supervising Manager / Reviewer
  Name of the supervisor who will approve this closure.

Reason for Closure

• Primary Reason for Case Closure
• Additional Detail on Closure Reason
  Provide any context that clarifies the closure reason, especially for 'Lost to Follow-Up', 'Administrative', or 'Other' selections.
• Number of Contact Attempts Before Closure (if applicable)
  Required for 'Lost to Follow-Up' closures. Document attempts per your agency's policy.

Services Delivered

• Services Provided During This Case
  Select all service types delivered to this client.
• If 'Other' service selected, describe
• Total Number of Service Contacts / Sessions
  Total documented contacts (in-person, phone, virtual) over the life of the case.
• Narrative Summary of Services Delivered
  Provide a concise narrative of the key services delivered and the client's engagement over the course of the case.

Goal Attainment

• Goal Attainment Summary
  List each goal from the service plan and rate its attainment at closure. Add a row for each goal.
• Overall Goal Attainment Rating
  Select the rating that best reflects the client's overall progress across all goals.
• Primary Barriers to Goal Achievement (if applicable)
  Select all barriers that significantly impacted goal attainment.

Post-Discharge Plan and Referrals

• Client's Status at Discharge
• Referrals Made at Discharge
  List each referral made, including the organization name, service type, and date of referral. Leave blank if no referrals were made.
• Client Provided Informed Consent for Referrals
  Confirm whether the client consented to information sharing with referred providers, per your agency's consent and data-sharing policy.
• Were there any unresolved safety concerns at the time of closure?
  If yes, document the steps taken and any mandatory reporting obligations fulfilled.
• Safety Concern Details and Actions Taken
  Describe the safety concern, actions taken, and any mandatory reporting completed. Do not include information that would re-identify third parties unnecessarily.
• Post-Discharge Plan Narrative
  Summarize the plan for the client after closure, including any self-sufficiency steps, ongoing supports, or follow-up scheduled.

Case Manager Attestation and Supervisor Review

• Case Record Completeness
  Confirm that the case record is complete before submitting for closure.
• Accuracy Attestation
• Case Manager Signature
  Electronic signature of the case manager submitting this closure.
• Date of Submission
• Supervisor Review Notes (completed by reviewer)
  Supervisor may add notes, corrections, or conditions for approval here prior to signing off.
• Supervisor Closure Decision
  To be completed by the approving supervisor.