Discharge Form
For DFR Staff Use Only.
CLIENT INFO
Client's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
INTAKE INFORMATION
Original Intake Date
*
-
Month
-
Day
Year
Date
Intake Type
*
Please Select
New Admission
Readmit
DFR Location
*
Please Select
DFR - 83rd
DFR - Modjeska
DFR - Jefferson
DFR -Glasgow
BRIDGES - Clyde
BRIDGES - Reading
BRIDGES - Holy Cross
IOP
*
Please Select
Nuview
Skyline
Create
Canyon
West LA
The Heights (Totality)
Exis
Silicone
Forward
Overland
Other
DISCHARGE INFORMATION
Discharge Date
*
-
Month
-
Day
Year
Date when billing will completely stop
Discharge Type
*
Please Select
Completion
Referred to Higher LOC
Admin Discharged
Left Voluntarily
For IOP or SLH Transfer, please use the Transfer form instead.
Eligible to Come Back? (For Use in Automated Follow-up)
*
Yes
No
Reason why not eligible? Needs to be accurate. (Used in determining if will be excluded in automated follow-ups)
*
PARENT/GUARDIAN INFO
Parent/Guardian/Relative Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Please Select
Family
Friend
Partner
Other
NOTES
Notes/Additional Information
STAFF INFORMATION
Completed By:
*
DFR Staff Email
*
Print
Save
Submit
Should be Empty: