Date of Discharge:
Date of last successful bidirectional contact:
Modality of last successful bidirectional contact:
Reason for Discharge: Doesn’t Meet Program Criteria
Was the member in agreement with termination at this time? N/A - Care Team reviewed member’s enrollment and/or intake information and determined that the member does meet program criteria AEB having no history of or current SUD. and as a result does not meet the program criteria for SELP.
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 needed referral and resources at time of discharge.
Signature: