6.SBH Long Term Bed Discharge Form

SBH Long Term Bed Discharge Form

Some question on this form are assigned a point value. This will allow us to determine the clients level of success and your input is invaluable. For a client to achieve a successful outcome, s/he MUST score a minimum of 65 points. Please answer each question thoughtfully as this will allow us to determine areas in the program that are strong and those we need to review.
Discharge Score
A score of 65+ equals a successful discharge. FOR ADMIN USE ONLY
Discharge Date*

MonthDayYear
Date
Name

First NameLast Name
Facility*
Was client employed on intake?*

YesNoNot medically cleared to work
Was client employed on discharge?*

Yes=10 pointsNo= 0 pointsNot medically cleared to work= 10 points
Did client reunify with his/her family while at Life Changes?*

Yes= 10 pointsNo= 0 pointsNot applicable= 10 points
Did client pay his/her service fees as required?*

Yes= 10 pointsNo= 0 pointsNot applicable= 10 points
Did client use drugs/alcohol while in the program?*

Yes= 0 pointsNo= 10 points
Was client clean/sober upon discharge from the program?*

Yes= 10 pointsNo= 0 pointsUnknown = 0 points
How many written notices of non compliance did client receive while in the program?*

Zero= 10 points2 or less= 5 points3 or more= 0 points
Length of Stay*

Less than 30 days= - 0 points30 to 60 days= 5 points60 to 90 days= 10 points90 plus days = 10 points
Do you recommend the client for successful discharge?*

Yes= 10 pointsNO= 0 points
Why did you recommend the discharge status indicated in the question above?*
Circumstance of Discharge*

Completed programNon compliance with program requirementsClient left of own accord prior to completionOther
Additional Comments
Staff Completing Form*

First NameLast Name
Should be Empty: