Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: No Intake
Was the member in agreement with termination at this time? N/A - Member stopped engaging with Care Team and did not complete intake with therapist within 45-days of enrollment.
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 did not complete intake and consistently engage with Care Team during time enrolled. Attempts were made via phone and text for the past 45 days without substantive response and a member no showed intake appointment(s). As such, member will be discharged per current guidelines.
Final DSM 5 Diagnoses:
Referrals Made: Therapist outreached member at the number on file to notify of discharge and to provide with 24/7 Mindoula Support Line should the member want to re-enroll.
Signature: