2. Residential Discharge

Name

First NameLast Name

Residents Current Phone #

Please enter a valid phone number.Format: (000) 000-0000.

Discharge Date

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?

Did client pay service fees as required

Did client use drugs/alcohol while in the program?

Was client clean and sober on discharge?

How many written notices of non-compliance did client receive while in the program?

Was the client employed on discharge?

Employment Status on Discharge

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?

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.

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

Did resident attend Life Skills group on Tuesday nights?

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

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