Mental Health Facility Discharge Form
Please complete the form to process the discharge from the mental health facility.
Patient 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
Primary Diagnosis
Summary of Treatment
Discharge Instructions
Follow-up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Approved By (Name and Title)
First Name
Last Name
Patient or Guardian Signature
Submit
Should be Empty: