Client Discharge Summary Form

1

House Manager Submitting Form:* This field is required.

First Name

Last Name

2

Member Name:* This field is required.

First Name

Last Name

3

Member Email Address:* This field is required.

example@example.com

5

Was this a successful discharge?

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

7

Discharge Date:* This field is required.

Date

8

Discharge Time:* This field is required.

Hour

Minutes

9

Post-Discharge Destination:* This field is required.

Sober Living

Treatment Center

Independent Living

Prison/Jail

Other / Unknown

10

Name of Post Discharge Location

11

Brief Summary of Discharge:* This field is required.Please give a description of the circumstances of this discharge.

12

Does this discharge need additional action?* This field is required.Ex: Client transitioned out on their own

YESNO

13

Does the client intend on continuing Clinical or Peer Services with us?

YESNO

14

What additional action is needed by the Program Manager?

15

Discharge Status Program Manager

16

Discharge Referrals - What referrals didi you give the client.

17

Operations Discharge Checklist

Stripe Invoice

Whatsapp Channels

EHR Discharge

Family / Emergency Contact Notification

18

Operations Discharge Status

19

SignatureI confirm the above stated is true and accurate to the best of my knowledge and the statements here in are true and correct.

Clear