Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Moved Out of Area
Was the member in agreement with termination at this time? Yes. Care Team informed member that they are not eligible for Mindoula program due to moving out of the area.
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 that they are moving to [insert information about move].
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: