Addiction Recovery Discharge Form
Please complete this form to document your discharge from the addiction recovery program.
Full Name
First Name
Last Name
Date of Admission
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Month
-
Day
Year
Date
Date of Discharge
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Month
-
Day
Year
Date
Reason for Discharge
Summary of Treatment
Follow-up Plan
Signature of Patient
Date of Signature
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Month
-
Day
Year
Date
Submit
Should be Empty: