Case Closure Form
Case Manager Name
First Name
Last Name
Case Record Number
Case Starting Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Case Ending Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason(s) for Closure
Services Provided and Progress Toward Goals
Does client aware of the case closure? (if applicable)
Yes
No
Not Applicable
Other
How was client notified?
Transfer, discharge, follow up, or other plans
Case Manager Signature
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor Signature
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Print
Submit
Should be Empty: