CG Hylton Inc. EFAP
Client Discharge Form
Client Name:
First Name
Last Name
Client Company:
Initial Contact Date:
-
Month
-
Day
Year
Date
Last Contact Date:
-
Month
-
Day
Year
Date
Certification Number:
Dates of service:
EAP Assessed Problem: (please check one)
Family/Child
Marital/Relationship
Alcohol
Drug Use
Child Abuse
Domestic Violence
Psychological
Family Violence
Medical
Occupational
Provisional Diagnosis
Anger Issues
Eating Related
Depression Related
Stress
Trauma
Were treatment/service goals met?
Yes
No
If no, please explain.
Reason for Discharge:
Client declined offered appointment times
Client failed to show and didn't reschedule
Client never called for initial appointment
Discharged against provider advice
Referred to community resources
Referred to impatient
Referred to outpatient
Referred to self-help
Treatment/service completed
Managed Care Service: (if applicable)
Treatment completed
Referred to other services
Client discharged against clinical advice
If referred, to whom?
Did client follow up with referral?
Yes
No
Submit
Should be Empty: