Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Needs Being Met By Another Provider
Was the member in agreement with termination at this time? Yes, member informed Care Team that their needs are being met by another provider.
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 their needs are being met by an alternative provider - [insert details of alternate provider here].
Final DSM 5 Diagnoses:
Referrals Made: Therapist outreached member at the number on file to notify of discharge and to provide with needed referral to [insert referral if applicable].
Signature: