Transition Planning Form

Current Medications (prescribed and non-prescribed)

	Strength	Dosage	Side Effects	Benefits
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Persons providing input used in the development of this plan (check all that apply):

Patient: *

Self Other:

Family Member(s): *

Spouse/Partner Parent Children Other:

Clinic Staff: *

Counselor Program Director Program Staff Physician Other:

Referral Source: *

- Other:

Legal System: *

Probation Officer Parole Officer Attorney Judge Other:

Friend/ Social Support: *

Roommate Friend Co-Worker Other:

Other: *

Employer Potential Employer Other:

Support systems needed to assist and support the patient in his / her process of continuing recovery / well‑being: *

Referral source information (include contact name, address, phone # , days and hours of service if applicable): *

	Contact Name	Address	Phone Number (###-###-###)	Day and Hours of Service	Date (mm/dd/yy) and Time (hh:mm PM/AM) of First Appointment (if applicable)
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Discharge Planning:

Options available if significant relapse occurs or if additional services are needed:

Call Quality Health Care Group @ (267)-949-6789 and communicate what is occurring.

Depending on the assessed need, re-admission may be advised and/or a referral to other care providers may be initiated.

Interest in returning to other community: Type answer here*

Referrals to local contact agencies or other appropriate entities made for the purpose above: Type answer here...*

Note: Please update the individual’s comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local agencies or other appropriate entities.

If discharge to the community is determined to not be feasible, please document who made the determination and why.

For residents who are discharged to SNF (skilled nursing facility), IRF (inpatient rehab facility), or LTCH (long-term care hospital) please assist the individual and their representatives in selecting a SNF (skilled nursing facility), IRF (inpatient rehab facility), or LTCH (long-term care hospital) standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available.

Clinic Staff responsible for follow-up after patient transition:

Patient Signature:   Signature      Date:   Date
My signature indicates that I have participated in this plan and have been offered a copy of it.
Counselor Signature:   Signature   Date:   Date

Quality Health Care Group Inc.

Transition Planning Form

S.N.A.P.