Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Completion/Graduation
Was the member in agreement with termination at this time?
If member did not return for scheduled appointment, list date of most recent attempt(s) made to contact member to reschedule:
Narrative Summary of Relevant Clinical Factors at time of Discharge:
Member has graduated from the program following completion of programmatic goals, including [add narrative].
Final DSM 5 Diagnoses:
Referrals Made: Care Team provided referrals for [input applicable discharge planning referrals provided].
Signature: