(AFFILIATED WITH BEHAVIORAL COUNSELING SERVICES, LLC)
Discharge Summary must be completed within 15 days of discharge.
PARTICIPANT ID NUMBER
Planned Discharge Date
Date Picker Icon
Actual Discharge Date
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Discharge Recipient Information
Recipients Relationship to Youth
Identification Items that were returned to youth (Click all that apply)
Social Security Card
Reason for Termination or Discharge: (Check One)
Child is considered a danger to himself or others as determined by a psychiatrist, psychologist.
Child is considered a danger to himself or others as determined by ADES and the Contractor.
Child is under the influence of drugs or alcohol and is in the need of detoxification.
Child is in need of emergency medical attention requiring in-patient hospitalization.
Child was arrested or placed in detention for more than 24 hours.
As mutually agreed between ADES and Contractor to move child to another placement.
ADES notifies the Contractor that the child will be moved to another placement
A voluntary agreement of child decided to terminate
AWOL (Away Without Leave)
List any future appointments and dates for youth:
Summary of Contacts between the licensee and person to whom child is being discharged to:
Summary of services provided for the youth while in care:
A list of medications provided during care including reasons for prescribing and outcomes:
A summary of progress towards service plan goals (if service plan established)
Assessment of the child"s unmet needs and alternative sources
Any after-care plan and person/agency responsible for follow-up services (If applicable)
If discharge was unplanned, give a description of circumstances and licensees actions to the cause this decision:
Are there any future suggestions or request for youth?
All belongings received by Youth?
Medications received by Youth?
Number of Medications received by Youth?
Names of Medication(s)?
COMPLETED BY (STAFF NAME)
Case Manager or Receiving Adult Signature
Should be Empty: