TERMINATION SUMMARY
Person’s Name (First MI Last): FORMTEXT ?????Record #: FORMTEXT ?????Date of Admission: FORMTEXT ?????Organization/Program Name: FORMTEXT ?????DOB: FORMTEXT ?????Gender: FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Transgender FORMCHECKBOX Transition - From (Unit/Program): FORMTEXT ?????To: FORMTEXT ????? FORMCHECKBOX Discharge Last Contact: FORMTEXT ?????Discharge/Transition Date: FORMTEXT ?????Person’s location and contact information post discharge/transition: Address: FORMTEXT ????? FORMCHECKBOX Unknown Telephone: FORMTEXT ????? FORMCHECKBOX UnknownIf discharged to shelter document efforts to prevent FORMTEXT ?????Status at Last Contact: FORMTEXT ?????Summary of Services/Treatment Provided (consider vocational, educational, financial legal, medical, behavioral, and risk status): FORMTEXT ?????Outcomes (Include qualitative and quantitative information regarding progress/gains achieved, strengths, abilities and preferences. Specify any standardized measures used): FORMTEXT ?????Health and Safety Concerns (include behavioral, medical and/or substance use issues): FORMCHECKBOX Not applicable FORMTEXT ?????Status Towards Meeting Goals (NM=Not Met, PM=Partially Met, M=Met, D/C=Discontinued)Goal #KeywordNMPMMD/CComments FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Overall Progress In Treatment: FORMTEXT ?????Diagnosis at Intake FORMCHECKBOX DSM-IV Codes FORMCHECKBOX DSM 5 Code FORMCHECKBOX ICD-9 Codes FORMCHECKBOX ICD-10 Codes Check Primary/Billing Diagnosis CodeNarrative Description FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? Diagnosis at Discharge/Transition FORMCHECKBOX DSM-IV Codes FORMCHECKBOX DSM 5 Code FORMCHECKBOX ICD-9 Codes FORMCHECKBOX ICD-10 Codes Check Primary/Billing Diagnosis CodeNarrative Description FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? Person’s Name (First / MI / Last): FORMTEXT ?????Record#: FORMTEXT ?????Reason for Discharge or Transition: FORMCHECKBOX Decrease level of care FORMCHECKBOX Increase level of care FORMCHECKBOX Goals met, no services needed FORMCHECKBOX Person terminated services FORMCHECKBOX Person refused referral for other services FORMCHECKBOX Involuntary discharge, person informed of right to appeal FORMCHECKBOX Person died FORMCHECKBOX Person moved FORMCHECKBOX Person did not return/was non-responsive to outreach attempts FORMCHECKBOX Other: FORMTEXT ?????If involuntary/administratively discharged, summary of action taken: : FORMCHECKBOX Not applicable FORMTEXT ????? Person Served notified of appeal process FORMCHECKBOX Yes FORMCHECKBOX No (explain) FORMTEXT ?????Person’s Response to Treatment and Discharge/Transition: FORMTEXT ?????Medications as Reported by Person at time of Discharge/Transition: FORMCHECKBOX None ReportedMedication NameDosePlans for Change - Including Rate of DetoxPrescribed by1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Referred To (Agency/Program Name, Location, and Contact Information):For (describe services/supports, rationale, list dates/times of appointments if known):Date(s)/Time(s) of Appts. If Known: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Aftercare Plan and Options (Include information on symptoms person should watch for, options available if these symptoms recur, additional services needed, and/or follow-up plans): FORMTEXT ?????Person’s Name (First / MI / Last): FORMTEXT ?????Record#: FORMTEXT ?????Person’s Signature (Optional, if clinically appropriate) FORMTEXT ?????Date: FORMTEXT ?????Parent/Guardian Signature (If appropriate): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider - Print Name/Credential: FORMTEXT ?????Date: FORMTEXT ?????Supervisor - Print Name/Credential (if needed): FORMTEXT ?????Date: FORMTEXT ?????Clinician/Provider Signature: FORMTEXT ?????Date: FORMTEXT ?????Supervisor Signature (if needed): FORMTEXT ?????Date: FORMTEXT ?????Psychiatrist/MD/DO (If required): FORMTEXT ?????Date: FORMTEXT ?????Was person provided copy of Discharge/Transition Plan? FORMCHECKBOX Yes, person given copy FORMCHECKBOX Yes, Person mailed copy FORMCHECKBOX No, person did not receive copy (explain): FORMTEXT ????? ................
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