Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Incarceration
Was the member in agreement with termination at this time? N/A - Care Team was informed that the member is incarcerated and unable to engage in services at this time as a result.
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: 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 upon release for post-incarceration support.
Signature: