DISCHARGE REQUEST FORM

Use this form to indicate when an individual is ready for discharge.

"*" indicates required fields

MM slash DD slash YYYY

Individual's Information

Name

Service Type

Service Type
Check box that best describes service that was provided.

Check All That Apply

Has Intake been completed?
Discharge Summary Completed?
If "DFCS Assessment" was selected, was the Case Closed or Treatment Completed?
If "DFCS Assessment" was selected, has the Authorization Ended?
Notes or Assessments still pending? (ie: to be reviewed/unassigned?)
Notes or Assessments that need signed?
Non-compliance Letter Sent?
Contact Log been updated?

Reason for Discharge

Check the main reason for discharge. The main reason should be congruent with what is written in the Discharge Summary. If no discharge summary check the reason that best describes.
Reason for Discharge
If "Other" was selected, describe circumstances.

Submitted By Information

Submitted by - Name*