Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Death
Was the member in agreement with termination at this time? N/A - Care Team was informed that member had passed away.
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:
Final DSM 5 Diagnoses:
Referrals Made: N/A OR Therapist provided [family/friend/spouse] with resources for grief and bereavement support in their area.
Signature: