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Client Discharge Summary Form
1
House Manager Submitting Form:
*
This field is required.
First Name
Last Name
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2
Member Name:
*
This field is required.
First Name
Last Name
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3
Member Email Address:
*
This field is required.
example@example.com
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4
Location
Tufts
Jay
Winona
Sully
Bryant Gardens
Penrose
Twin Lakes
Zuni
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5
Was this a successful discharge?
Please Select
Yes
No
Unsure
Please Select
Please Select
Yes
No
Unsure
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6
Reason for discharge
Alumni - Graduated the program
Positive Discharge - Non Graduate
Relapse - opportunity to return
Relapse - breached cardinal rules
Program non-compliance
Danger to community
Non-payment
Failed to meet scholarship conditions
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7
Discharge Date:
*
This field is required.
-
Date
Year
Month
Day
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8
Discharge Time:
*
This field is required.
1
2
3
4
5
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7
8
9
10
11
12
1
2
3
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7
8
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Hour
00
10
20
30
40
50
00
10
20
30
40
50
Minutes
AM
PM
AM
AM
PM
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9
Post-Discharge Destination:
*
This field is required.
Sober Living
Treatment Center
Independent Living
Prison/Jail
Other / Unknown
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10
Brief Summary of Discharge:
*
This field is required.
Please give a description of the circumstances of this discharge.
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11
Does this discharge need additional action?
*
This field is required.
Ex: Client transitioned out on their own
YES
NO
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12
What additional action is needed by the Program Manager?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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13
Discharge Status Program Manager
Please Select
NEW / OPEN
In progress
Complete
NEW / OPEN
Please Select
NEW / OPEN
In progress
Complete
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14
Operations Discharge Checklist
Stripe Invoice
Whatsapp Channels
EHR Discharge
Family / Emergency Contact Notification
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15
Operations Discharge Status
Please Select
Open
In progress
Complete
Open
Please Select
Open
In progress
Complete
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16
Signature
I confirm the above stated is true and accurate to the best of my knowledge and the statements here in are true and correct.
Clear
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