2. Residential Discharge

Residential Discharge

Revised 4/2023
Name*

First NameLast Name
Residents Current Phone #*
Please enter a valid phone number.
Discharge Date*

MonthDayYear
Date
Facility*
PO or Case Manager Name*
This form will auto calculate the discharge score based on data entered. A score of 45 or above will indicate a successful completion of the preestablished program components. This discharge score will be paired with the percentage of personal goal achievement to determine final discharge score for each resident.

Be sure to case note clients personnal goal achievement as part two of his/her discharge documentation. Your discharge along with the residents personal goal achievement will determine the client discharge status.
Discharge Score: Part 1
Resident must achieve a minimum of 45, out of a possible 60 points, to be considered for a successful program completion.
Did client reunify with family while at Life Changes?*

Yes - 10 PointsNo - 0 PointsClient does not have family or family reunification not possible - 10 points
Did client pay service fees as required*

Yes - 10 PointsNo - 0 PointsClient has an outside source of payment - 10 Points
Did client use drugs/alcohol while in the program?*

Yes - 0 PointsNo - 10 Points
Was client clean and sober on discharge?*

Yes - 10 PointsNo - 0 Points
How many written notices of non-compliance did client receive while in the program?*

Zero - 10 PointsLess than two - 5 PointsThree or more - 0 Points
Was the client employed on discharge?*

Yes - 10 PointsNo - 0 PointsNot medically cleared to work - 10 points
Employment Status on Discharge*

Employed minimum wage up to $15Employed $16-$20 per hourEmployed $21 - $ $26 per hourEmployed $27 per hour and upN/A
Where did client transition to?*
If you selected OTHER for Transition, where did client go?
What personal goals did client achieve while in the program?*
What Languages does resident speak? E.G. English, Spanish, etc.*
Is resident in compliance with Criminal Justice Mandates?*

YesNoDoes not apply
Did you work with resident on a relapse prevention plan? Meaning, did you help resident recognize triggers for relapse, identify what to do when that happens, who to call, etc.*

YesNo
Did you help resident fill out an application for other housing?*

YesNo
Did resident attend Life Skills group on Tuesday nights?*

YesNo
What resources, if any, did you refer the resident to?
Comments
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