Discharge Summary or Transition Plan
| | |MENTAL HEALTH CENTER |
|Discharge Summary or Transition Plan |
This form is being used to (check one): Discharge from MHC services Transfer to another program
|Client Name: |CID#: |Date of Admission: |Date of Discharge/Transition: |
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|Reason for Discharge/Transition: |
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|Diagnosis at Admission: |Diagnosis at Discharge/Transition: |
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|GAF at Admission: | |GAF at Discharge/Transition: | |
|Strengths: |Needs: |Abilities: |Preferences: |
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|Current Medications (list medications, dosages): |
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|Will the client be discharged/transferred on medication? Yes No |
|Explain. | |
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|Presenting Condition/Problem(s)/Symptom(s): |
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|What services were provided and what were the results of services/progress on recovery at the time of discharge/transition |
|(Include the following: Were goals/objectives met? Gains achieved? Progress in his/her recovery?): |
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|Date of Last Contact: |Client Status at Last Contact: |
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|Recommendations for Follow-up/Support (include information about referrals to other agencies): |
|1). If symptoms re-appear you may return to the mental health center for further evaluation and treatment. |
|2). Referred to |
|Program Transfer Information: |
|Sending Staff: | | |Receiving Staff: | | |
|Transferred From: | | |Transferred To: | | |
|Admission Date to Currently Assigned Program: | | |
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|Person participating in Discharge Summary/Transition Plan: | |
|Staff Signature/Title/Date: | |
|Client received a copy of the Discharge Summary/Transition Plan: Yes No |
SCDMH FORM
APR. 99 (REV. APR 2010) C-52
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