Request Self Discharge
Self-Discharge Patient from Psychvisit-To Close Your Chart and END Treatment
Date of Request:
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Month
/
Day
Year
Patient Name:
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First Name
Last Name
Clinician You See in the Practice:
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Faisal Rafiq MD.
Joan Mahoney NP.
Yasmine Saim, MMSc, PA-C
Pick the Reason for Your Discharge Request from the Practice:
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Improvement in Condition: The patient feels they have recovered sufficiently and no longer need psychiatric services.
Lack of Improvement: The patient doesn't see the expected benefit or improvement and may seek alternative treatments.
Change in Diagnosis: A re-evaluation of the initial diagnosis could lead to a decision to pursue other specialized care.
Relocation: The patient moves to a different geographic area and needs to switch to a more local provider.
Change in Insurance: The patient's insurance coverage changes, making treatment unaffordable or unavailable at your practice.
Scheduling Conflicts: The patient finds it difficult to match their schedule with the available appointment times.
Change in Treatment Preference: The patient may prefer a different type of therapy or medication not offered at your practice.
Provider Mismatch: The patient may feel they are not sufficiently compatible with the psychiatrist or other staff.
Desire for a Second Opinion: The patient wishes to consult another healthcare professional for their psychiatric care.
Cost of Treatment: The out-of-pocket expenses may become too burdensome for the patient.
Stigma: Concerns about social stigma related to psychiatric treatment may cause some patients to self-discharge.
Family or Peer Influence: Opinions from family or peers may discourage continuing treatment.
Privacy Concerns: The patient may have concerns about how their information is being stored or used.
Communication Issues: Poor communication from the practice's end might make a patient feel less inclined to continue their treatment.
Other
Feedback or Comments (Optional)
Close My Chart
Should be Empty: