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
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Discharge
Summary of Treatment
Follow-up Plan
Signature of Patient
Date of Signature
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: