Better Together Mesa
Discharge Summary
Must be completed within 15 days of discharge
Youths Name
*
First Name
Last Name
Date of Discharge
*
-
Month
-
Day
Year
Date
Name of person the youth was discharged to
*
First Name
Last Name
Relationship to Youth
*
Phone number of person youth was discharged to
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of person youth was discharged to
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Planned discharge date
*
-
Month
-
Day
Year
Date
Actual discharge date
*
-
Month
-
Day
Year
Date
Summary of contacts between the licensee and person to whom child was discharged
*
Summary of services provided while in care
*
A list of medications provided during care including reasons for prescribing and outcomes
*
Summary of progress toward service plan goals
*
Assessment of the youths unmet needs and alternative sources
*
Any after-care plan and person/agency responsible for follow-up services
*
If discharge was unplanned, description of circumstances and licensees actions
Youths Signature if applicable
Date
-
Month
-
Day
Year
Date
Manager Signature
*
Date
*
-
Month
-
Day
Year
Date
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