Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Member Opted-Out
Was the member in agreement with termination at this time? Yes, member requested to opt-out of services at this time, reporting that they are no longer needed.
CTM asked:
Could you tell me more about what made you change your mind about participating in our program? The member stated, "[Response here]."
Is there anything we could adjust in services to help you feel better about your participation in the program? The member stated, "[Response here]."
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 reported no longer needing Mindoula services at this time because [insert narrative and clinically relevant information].
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 in services if they become needed.
Signature:
Date of Discharge: