DISCHARGE REQUEST FORM Use this form to indicate when an individual is ready for discharge. Date Submitted Date Format: MM slash DD slash YYYY Individual's InformationName First Middle Last Suffix Submitted By InformationSubmitted by - Name First Last Submitted by - Email Service TypeService Type Counseling Intake DFCS Assessment DFCS Assign Other Check box that best describes service provided.If "Intake" was selected, was Intake completed? Yes No If "DFCS Assessment" was selected, was the Case Closed or Treatment Completed? Yes No Check All That ApplyIf "DFCS Assessment" was selected, has the Authorization Ended? Yes No Discharge Summarry Completed? Yes No Not Required Notes or Assessments still pending? (ie: to be reviewed/unassigned?) Yes No Notes or Assessments need signed? Yes No Was Non-compliance Letter Sent? Yes No Not required Contact Log Updated? Yes No Reason for DischargeCheck 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 Goals Met Treatment Completed Succesful Discharge Non-Compliant Refused Treatment Unsuccessful Referred to Another Provider Transitioned Interrupted Client No Longer Available Moved Out of the Area Aged Out Incarcerated Deceased Inappropriate for Services Lost Medicaid Service Denied by Insurance Company Duplicate Individual Other (Explain Below) "Other" DescriptionIf "Other" was selected above, describe circumstances.Additional Notes concerning Reason for DischargeApproval InformationSignature of ApprovalName First Last Visits: 341
