Holistic Health Discharge Form
Please complete this form to finalize your discharge process and ensure continuity of your holistic health care.
Client Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Session/Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Practitioner Name
*
First Name
Last Name
Type of Treatment or Session Provided
*
Please Select
Massage Therapy
Acupuncture
Reiki or Energy Healing
Nutritional Counseling
Herbal Consultation
Other
Reason for Discharge
*
Treatment Completed
Client Request
Referral to Another Provider
Non-compliance with Plan
Other
Summary of Services Provided and Progress Notes
*
Aftercare Recommendations or Follow-Up Instructions
*
Client Feedback: How satisfied are you with your holistic health experience?
1
2
3
4
5
Additional Comments or Suggestions
Client Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: